What are the key clinical features that suggest a diagnosis of endometriosis in a patient presenting with pelvic pain?

Key clinical features suggesting a diagnosis of endometriosis in a patient presenting with pelvic pain include:

• Chronic pelvic pain that may be persistent or cyclical, often worsening around menstruation (dysmenorrhoea) and significantly affecting daily activities and quality of life NICE NG73.
• Deep dyspareunia, which is pain during or after sexual intercourse, is a common symptom associated with endometriosis NICE NG73.
• Period-related or cyclical gastrointestinal symptoms, such as painful bowel movements, and urinary symptoms including pain on passing urine or haematuria, may also be present NICE NG73.
• Infertility occurring alongside one or more of the above symptoms increases suspicion of endometriosis NICE NG73.
• A family history of endometriosis in first-degree relatives raises the likelihood of the diagnosis and should be actively sought NICE NG73.
• On physical examination, pelvic signs such as tender nodularity in the posterior vaginal fornix, reduced organ mobility, pelvic masses, or visible vaginal endometriotic lesions may be found, although a normal pelvic exam does not exclude the diagnosis NICE NG73.
• Imaging, particularly transvaginal ultrasound, can identify endometriomas and deep infiltrating endometriosis involving bowel, bladder, or ureter, aiding diagnosis though a normal scan does not exclude endometriosis NICE NG73,NICE CKS.
• Laparoscopic visualization remains the definitive diagnostic method, with systematic inspection of the pelvis and biopsy of suspected lesions to confirm diagnosis and exclude malignancy if necessary NICE NG73.
• Recent literature supports these clinical features and highlights the heterogeneity of presentation, noting that symptoms may overlap with other pelvic pathologies and that inflammatory and neuropathic pain mechanisms contribute to the clinical picture Foti et al. 2018Fiorillo et al. 2024.

In summary, the diagnosis of endometriosis should be considered in women presenting with chronic pelvic pain, dysmenorrhoea, deep dyspareunia, cyclical bowel or urinary symptoms, and infertility, especially with a positive family history and supportive pelvic examination or imaging findings. Definitive diagnosis requires laparoscopy, but clinical suspicion guides initial management and referral NICE NG73,NICE CKS Foti et al. 2018Fiorillo et al. 2024.