Intended for healthcare professionals

Practice Easily Missed?


BMJ 2022; 379 doi: (Published 28 November 2022) Cite this as: BMJ 2022;379:e068950
  1. Louie Ye, RANZCOG trainee/clinical fellow1 2,
  2. Lucy H R Whitaker, NES/CSO clinical lecturer in obstetrics and gynaecology3,
  3. Rebecca L Mawson, GP and academic training fellow4,
  4. Martha Hickey, Professor of Obstetrics and Gynaecology1 2
  1. 1The Royal Women’s Hospital, Melbourne, Victoria, Australia
  2. 2Department of Obstetrics and Gynaecology, University of Melbourne and the Royal Women’s Hospital, Victoria, Australia
  3. 3MRC Centre for Reproductive Health, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, UK
  4. 4The Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
  1. Correspondence to M Hickey hickeym{at}

What you need to know

  • Consider endometriosis when women of reproductive age present with abdomino-pelvic pain associated with menstruation, sexual intercourse, urination, defecation, and/or infertility

  • Consider gynaecology referral if three months of simple analgesia (with or without combined oral contraceptive pill) is ineffective for suspected endometriosis

  • A normal pelvic exam and/or pelvic ultrasound does not exclude endometriosis

A 24 year old woman presents to a new GP with threeyears of pain during sexual intercourse and increasingly painful periods affecting her mood, relationships, and work. Simple analgesia was ineffective and pelvic ultrasound within three months was normal. She has presented fivetimes in the past two years but has received no diagnosis or effective management.

What is endometriosis?

Endometriosis is a condition defined by the presence of endometrial-like tissue outside the uterus.1It typically occurs in women of reproductive age but prepubertal endometriosis has been reported. Endometriosis is also reported in women after menopause but is thought to have developed prior to menopause.23 Globally, it affects 190 million women and those assigned female at birth, but a UK survey in 2017 reported that only 20% of the general public had ever heard of it.4 Subtypes5 include superficial peritoneal (as visualised at laparoscopy, and the most common type); deep (depth of penetration ≥5 mm); and ovarian (ovarian cysts with endometriosis content, also known as endometriomas). In women with endometriosis, 17-44% have an ovarian endometrioma.67 Less frequently, endometriosis occurs at other anatomical locations such as the thorax or previous surgical incision sites.1

Long term consequences include impaired quality of life, anxiety, depression, and self-harm.89 Central pathway sensitisations may also lead to chronic pain syndromes.10 Symptom severity is frequently discordant between disease subtype and extent1 and data pertaining to natural history are limited, particularly when disease is found incidentally …

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