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Thinking of Endometriosis: Atypical Presentations

Endometriosis is a common condition that frequently goes unrecognised. It is due to the endometrial cells being found away from the uterine lining, and the sites the cells are lodged in will determine certain complications, such as infertility and pain.1The symptoms of the condition vary with the individual woman, cultural attitudes, her pain threshold and the severity and site of the endometriosis. For this reason, it is important to be aware of atypical presentations.

Typical symptoms of endometriosis are pain beginning a day or two before the onset of menstruation, spotting during this time, severe pain, especially persisting after the first two days of bleeding, and especially if occurring, more than the first two or three years after menarche. Endometriosis is associated with heavy periods and periods lasting longer than five days.1 It is known that approximately one third of women with endometriosis do not know that they have the condition and it is found incidentally at the time of an abdominal operation or investigation for infertility.1 It is also true that the apparent severity of the endometriosis has an unreliable relationship to the severity of pain.1

Other symptoms that need to be specifically asked for include pelvic pain during sex, pain with defaecation or urination during menstruation, bleeding from the bowel or urinary tract around the time of menstruation, symptoms of “irritable bowel” such as pain with passing wind, constipation or diarrhoea, bloating and nausea just before and during periods, and low back pain, groin pain or pain radiating to the upper thigh occurring during bleeding.1 Endometriosis is also more likely if there is a family history of the condition.1

Endometriosis affects not just patient’s comfort, quality of life, sex life and fertility, but also the woman’s ability to earn an income. This is often forgotten, and is linked not just with job security and advancement but also with self-esteem and independence. Every patient with severe period pain should be asked about how their problem affects their work and general well-being. It is NOT normal to have to take time off work for severe period pain, especially if the woman requires anti-inflammatories or other pain medications frequently during menstruation.1 Depression and anxiety are not uncommon in women who have symptomatic endometriosis.1

The history and physical examination are crucial. A bimanual internal examination may diagnose tethering of the uterus and fallopian tubes, forniceal masses from endometriomas and suggest the site of pain. An ultrasound of the pelvis is the next most important general practice investigation but does not usually identify endometriosis, unless there are structural abnormalities (such as endometriomas) present. This investigation may, however, exclude other differential diagnoses, such as polycystic ovarian syndrome. The gold standard test for endometriosis is laparoscopic visualisation and this is important to do early when considering endometriosis,2as the condition progresses with time if not appropriately treated.1

Fertility in women who have endometriosis is affected in a number of ways. Structural changes occur from scarring, endometriomas, impaired ovulation, oocycte and sperm movement; chemically, chronic inflammation impairs fertility; hormonally, there is an anti-progestogen effect.2 Women who have endometriosis should be asked about plans for pregnancies and should be warned about the possibility of impaired fertility. If conception has not occurred naturally within a reasonable period of time (this will vary with the age of the patient, site and severity of the endometriosis and past obstetric history) referral to an infertility specialist should be suggested.


1. Jean Hailes for Women’s Health: Endometriosis

2. Koch  J., et al. Endometriosis and Infertility – a consensus statement from ACCEPT.
Australian and New Zealand Journal of Obstetrics and Gynaecology 2012; 52: 513-22