Endometriosis should be suspected in women with any of the following symptoms. Remember, however, about 30% of patients with endometriosis do not have any pain.

• dysmenorrhea (menstrual cramps, particularly those that worsen with time and are unresponsive to medical therapy)
• dyspareunia (pain with intercourse, particularly on deep penetration)
• "aching" or cramping following intercourse
• dyschezia (pain with bowel movements, particularly noticable near the menses)
• hematochezia (blood in the bowel movement unrelated to known problems such as hemorrhoids)
• dysuria (pain with urination, unrelated to bladder infections)
• hematuria (blood in the urine unrelated to any infection)
• mittelschmerz (pain with ovulation, particularly that which worsens with time)
• focal or generalized recurrent pelvic pain

During pelvic examination, the astute gyncologist suspects endometriosis when any ofthe following are discovered:

• tenderness or nodularity in the posterior cul-de-sac, especially on the uterosacral ligaments
• anterior cul-de-sac nodularity
• adnexal masses
• reduced mobility or fixation of the uterus or ovaries
• unusual pain associated with the examination

Few tests assist in the diagnosis of endometriosis. Transvaginal ultrasonography is commonly used to evaluate the adnexa for endometriomas. Unfortunately, there are no currently available blood tests that will reliable aid in the diagnosis of endometriosis. CA-125 may occasionally be helpful in following the course of endometriosis after diagnosis and treatment, but it offers nothing in the diagnosis.

Currently the only definitive test for pelvic endometriosis is laparoscopy. Biopsy of lesions may sometimes be necessary to confirm the diagnosis, and should always be performed if there is any question. When advance endometriosis is suspected, preoperative consultations with gastroenterologists, urologists, or other specialists should be scheduled to ensure that the disease is optimally treated at the time of initial diagnosis. All of these specialists should be familiar with laparoscopic techniques for the treatment of advanced endometriosis.

It has been estimated that the diagnosis of endometriosis is missed in more than 7% ofpatients, and the extent of disease is underestimated in as many as 50% of patients. Subtle lesions can be missed even by experienced laparoscopists. Other lesions such as old suture, ovarian cancer, carbon deposits from prior laser surgery, and hemangiomas may be mistaken for endometriosis.