**8. Physical examination**

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).
