GPAtlas🧭 When to suspect
Endometriosis is the growth of endometrial-like tissue outside the uterus – most often on the pelvic peritoneum, ovaries (forming endometriomas, the "chocolate cyst") and uterosacral ligaments. It is a chronic, oestrogen-dependent inflammatory condition affecting roughly 1 in 10 women and people assigned female at birth of reproductive age – around 1.5 million in the UK.
The defining clinical problem is delayed diagnosis: the average woman waits years – often cited as around 8 years – from first symptom to diagnosis. The single most useful thing a GP can do is think of it early, validate the symptoms, and start managing them rather than waiting for a "definitive" test.
Suspect endometriosis in anyone (including young people aged 17 and under) with one or more of: chronic pelvic pain (pelvic pain for 6 months or longer); period-related pain (dysmenorrhoea) affecting daily activities and quality of life; deep pain during or after sex (dyspareunia); cyclical or period-related bowel symptoms, especially painful bowel movements (dyschezia); cyclical or period-related urinary symptoms, especially blood in the urine or pain passing urine; or infertility in association with any of the above. Fatigue and a significant psychological and social impact are common. Ask about a first-degree family history of endometriosis, which increases the likelihood.
Symptoms may be cyclical at first but can become constant. Crucially, a normal examination and a normal ultrasound do not exclude endometriosis – a working ("suspected") diagnosis is valid, and symptoms should be treated while investigation and referral proceed in parallel.
| Also consider (differential or coexisting) | Discriminating features |
|---|---|
| Adenomyosis | Bulky, tender uterus; heavy and painful periods; often older or parous. Frequently coexists with endometriosis. |
| Pelvic inflammatory disease | Deep dyspareunia with abnormal discharge, cervical motion tenderness, STI risk factors; may be febrile. |
| Irritable bowel syndrome | Bloating and altered bowel habit related to defaecation; symptoms not confined to menstruation. Often coexists. |
| Bladder pain syndrome / interstitial cystitis | Bladder pain with urinary urgency and frequency but sterile urine (no infection). |
| Ovarian cyst (incl. endometrioma) | Adnexal mass; consider acute torsion or rupture if pain is sudden and severe. |
| Primary dysmenorrhoea | Pain from menarche, no other features and a normal examination. |
| Pelvic floor / musculoskeletal pain | Localised, often non-cyclical and positional tenderness; reproduced on palpation of the pelvic floor. |
Source: NICE NG73
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