Endometriosis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2]

Overview

Endometriosis causes dysmenorrhea and dyspareunia. Endometriosis must be differentiated from other conditions presenting with dyspareunia and dysmenorrhea such as adenomyosis, pelvic inflammatory disease, pelvic congestion syndrome, and sub-mucosal uterine fibroids.

Differential Diagnosis

Endometriosis is a cause of abnormal uterine bleeding and can result in infertility. There are several diseases which can result in excessive uterine bleeding. The following table is a description of the various diseases that cause abnormal uterine bleeding.

Differentiating Endometriosis on the Basis of Abnormal Uterine Bleeding:

	Clinical Features	Physical Examination	Diagnostic Findings
Endometriosis	Dysmenorrhea Dyspareunia Infertility Common in women between 25 to 35 years	Nodules in the posterior fornix Adnexal masses Fixed retroverted uterus Lateral displacement of the cervix	Increased serum cancer antigen-125  Nodules of the recto vaginal septum and hypoechoic, vascular mass on MRI Laparoscopic visualization confirms the diagnosis
Adenomyosis	Abnormal uterine bleeding Dysmenorrhea Common in women between 40 and 50	Diffuse uterine enlargement always less than size corresponding to less than 12 weeks of gestation	Asymmetric thickening of the myometrium on MRI
Submucous uterine leiomyomas	Menorrhagia Pelvic pressure and pain Infertility Peak age of onset 25 to 44 years of age	Mobile uterus with an irregular contour	Transvaginal ultrasound will demonstrate the presence of myomas
Pelvic inflammatory disease	Seen in patients with history of sexually transmitted disease History of multiple sexual partners  Common in women younger than 25 years of age	Abdominal tenderness  Acute cervical motion, uterine, and adnexal tenderness Visualization of purulent endocervical discharge	Positive nucleic acid amplification tests for Chlamydia trachomatis and N. gonorrhea Gram negative diplococci on gram stain
Pelvic congestion syndrome	Shifting lower abdominal pain Deep dyspareunia Post-coital pain Exacerbation of pain after prolonged standing	Bimanual tenderness Cervical motion tenderness	Pelvic varicosities on ultrasound with reduced blood flow

Differentiating Endometriosis on the Basis of Lower Abdominal Pain:

Endometriosis can also be differentiated from conditions that present with lower abdominal pain in young women. The following is a list of diseases that present with acute onset severe lower abdominal pain:

Disease	Findings
Ectopic pregnancy	History of missed menses; positive pregnancy test; ultrasound reveals an empty uterus and may show a mass in the fallopian tubes.
Appendicitis	Pain localized to the right iliac fossa; vomiting; abdominal ultrasound sensitivity for the diagnosis of acute appendicitis is 75% to 90%.
Rupturedovarian cyst	Usually spontaneous; can follow the history of the trauma; mild chronic lower abdominal discomfort may suddenly intensify; ultrasound is diagnostic.
Ovarian cyst torsion	Presents with acute severe unilateral lower quadrant abdominal pain, nausea, and vomiting; tender adnexal mass palpated in 90%; ultrasound is diagnostic.
Hemorrhagic ovarian cyst	Presents with localized abdominal pain, nausea, and vomiting; Hypovolemic shock may be present; abdominal tenderness and guarding are physical exam findings; ultrasound is diagnostic.
Endometriosis	Presents with cyclic pain that is exacerbated by the onset of menstruation and dyspareunia. Laparoscopic exploration is diagnostic.
Acute cystitis	Presents with features of increased urinary frequency, urgency, dysuria, and suprapubic pain.