**9. Differential diagnosis**

The symptoms of endometriosis are nonspecific and may mimic many disease processes. Because endometriosis is a surgical diagnosis, several other diagnoses may be considered prior to surgical exploration. Since there is such an extremely variable presentation, an accurate differential diagnosis should always be performed in patients suspected of endometriosis. First of all, other gynecological disorders, such as ovarian and tubal diseases, pelvic inflammatory disease and ectopic pregnancy, should be excluded (16). Then a series of gut disorders should be considered; among these conditions, irritable bowel syndrome

classification of endometriosis, which describes the extent of disease bulk, poorly predicts symptoms. Thus clinically, women with extensive disease (stage IV) may note few complaints, whereas those with minimal disease (stage I) may have significant pain or

The following symptoms can be caused by endometriosis based on clinical and patient

• Cyclical or perimenstrual symptoms (e.g. bowel or bladder associated) with or without

However, the predictive value of any one symptom or set of symptoms remains uncertain as each of these symptoms can have other causes. A large group of women with endometriosis is completely asymptomatic. In these women endometriosis remains undiagnosed or is diagnosed atlaparoscopy for another indication. A subset of women with more advanced disease, ovarian or deep invasive rectovaginal endometriosis, is asymptomatic as well. This makes the development of guidelines for the diagnosis and the therapy rather cumbersome. Endometriosis should be suspected in women with dysmenorrhoea, deep dyspareunia,

Physical examination of the pelvis is useful for the diagnosis of deep infiltrating lesions or endometriotic cysts. The examination may be normal. It is more reliable when carried out during the menstrual period. Examination of the retrocervical area using the speculum, by vaginal and (possibly) rectal examination, is recommended. Examination of the vagina and cervix by speculum examination often reveals no signs of endometriosis. Occasionally, bluish or red powder-burn lesions may be seen on the cervix or the posterior fornix of the vagina. Pelvic organ palpation often reveals anatomic abnormalities suggestive of endometriosis. Uterosacral ligament nodularity and tenderness may reflect active disease or scarring along the ligament. In addition, an enlarged cystic adnexal mass may represent an ovarian endometrioma, which may be mobile or adherent to other pelvic structures (15, 63).

The symptoms of endometriosis are nonspecific and may mimic many disease processes. Because endometriosis is a surgical diagnosis, several other diagnoses may be considered prior to surgical exploration. Since there is such an extremely variable presentation, an accurate differential diagnosis should always be performed in patients suspected of endometriosis. First of all, other gynecological disorders, such as ovarian and tubal diseases, pelvic inflammatory disease and ectopic pregnancy, should be excluded (16). Then a series of gut disorders should be considered; among these conditions, irritable bowel syndrome

subfertility or both (68, 69).

• Severe dysmenorrhoea; • Deep dyspareunia; • Chronic pelvic pain; • Ovulation pain;

abnormal bleeding;

**8. Physical examination**

**9. Differential diagnosis** 

acyclic chronic pelvic pain and/or subfertility.

experience:

• Infertility; • Chronic fatigue. (IBS) is worthy of particular attention (70). Crohn's disease should also be considered in the differential diagnosis of endometriosis, since this condition shows several similarities regarding both the locations and the anatomo-pathologic pattern (71). Although rare, familial Mediterranean fever (FMF) should be considered in the differential diagnosis of endometriosis (72). Rarely the presence of parasitic infestations has been reported in women with symptoms suggestive of endometriosis (73).
