Intended for healthcare professionals

Practice Easily Missed


BMJ 2010; 340 doi: (Published 23 June 2010) Cite this as: BMJ 2010;340:c2168
  1. Samuel Engemise, clinical research fellow in obstetrics and gynaecology1,
  2. Cerys Gordon, general practitioner2,
  3. Justin C Konje, professor of obstetrics and gynaecology1
  1. 1Reproductive Sciences Section, Department of Cancer Studies and Molecular Medicine, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester LE2 7LX
  2. 2South Wigston Health Centre, Wigston LE18 4SE
  1. Correspondence to: J C Konje jck4{at}
  • Accepted 1 April 2010

Case scenario

A 26 year old presents with several years of severe dysmenorrhoea (with little relief from non-steroidal anti-inflammatory drugs) and dyspareunia which is increasingly affecting her relationship with her partner. Her general practitioner suspects endometriosis, as endocervical swabs show no evidence of infection and her symptoms improve slightly after he advises her to take the pill continuously. He refers her to a gynaecologist with interest in endometriosis for more definitive management of her symptoms. Laparoscopy confirms the diagnosis and she is successfully managed with a gonadotrophin releasing hormone agonist pill for six months.

Endometriosis is the presence of functional endometrial glands and stroma at various extrauterine sites in women, predominantly those of reproductive age, from all ethnic and social groups. It is a common, benign, oestrogen dependent, chronic gynaecological disorder and a common cause of chronic pelvic pain in women presenting in primary care. Other symptoms include dysmenorrhoea, deep dyspareunia, and infertility, all of which can have an impact on the physical, mental, and social wellbeing of these women.

How common is it?

Endometriosis is estimated to affect 5-10% of women in the reproductive age group.1 Prevalence is difficult to determine due to difficulties in diagnosis caused by the diversity of symptoms and their severity and because endometriosis may be asymptomatic.

Why is it missed?

Endometriosis is often labelled “the missed disease”2; in the United Kingdom the average time between onset of symptoms and a definitive diagnosis is 7-8 years.3 This delay is usually due to failure to recognise the nature of the symptoms of endometriosis. Diagnosing the condition on the basis of symptoms alone can be difficult as they are so variable (table) 4 5 6 7 and overlap considerably with those of other conditions, such as …

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