• Suspect endometriosis in women who present with:
• Secondary dysmenorrhoea (which may be severe) — usually before or during menstruation.
• Deep dyspareunia.
• Chronic pelvic pain.
• Ovulation-related pain.
• Cyclical or peri-menstrual bowel or bladder symptoms, with or without abnormal bleeding or pain.
• Subfertility.
• Pain on defecation (especially during menses).
• Painful Caesarean-section scar.
• Painful micturition (especially during menses). This is very rare.
• In adolescents, consider endometriosis if pain is unresponsive to the combined oral contraceptive pill and to nonsteroidal anti-inflammatory drugs.
• Examination is likely to be normal, as most endometriosis is mild or moderate in severity. However, more extensive endometriosis should be suspected if, on a speculum and bimanual pelvic examination:
• There is localized pelvic tenderness, a fixed retroverted uterus, tenderness of the uterosacral ligaments, or enlargement of the ovaries (due to cystic lesions).
• There are palpable nodules on the uterosacral ligaments (like a string of beads) or in the pouch of Douglas. Nodules are more likely to be felt during menstruation but pelvic examination at this time is not acceptable to many women.
• Lesions are visible in the vagina or on the cervix.
• Consider referring all women with suspected endometriosis, as laparoscopy is usually required to confirm the diagnosis.

These recommendations are based on expert advice in guidelines published by the Royal College of Obstetricians and Gynaecologists [RCOG, 2006] and the European Society of Human Reproduction and Embryology [Kennedy et al, 2005], and two non-systematic reviews [Brosens, 1997; Farquhar, 2007].

• A non-systematic review found that [Laufer et al, 2003]:
• Endometriosis in adolescents may present with acyclic, cyclic, or continuous pelvic pain.
• Several studies have shown that between 50% and 70% of adolescents undergoing laparoscopy for pelvic pain unresponsive to nonsteroidal anti-inflammatory drugs and the combined oral contraceptive pill have endometriosis.

• Consider other conditions that may present with similar symptoms:
• Uterine causes, such as adenomyosis or uterine fibroids.
• Adhesions.
• Interstitial cystitis or recurrent urinary tract infections.
• Irritable bowel syndrome or other bowel pathology.
• Pelvic inflammatory disease.
• Primary dysmenorrhoea.
• Musculoskeletal disorders, such as referred pain from degenerative disc disease of the spine.
• Malignancy (of the cervix, uterus, ovary, rectum, or bladder).
• Congenital anomalies of the reproductive tract.

• These recommendations are based on expert advice in two textbooks [Edmonds, 1999; Drife and Magowan, 2004b] and a non-systematic review [Practice Committee of the American Society for Reproductive Medicine, 2008].