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Ten percent of women will develop endometrosis characterized by the presence of endometrial tissue at sites outside the uterine cavity. The ectopic endometrial cells cause the cyclical dysmenorrhea of endometrosis.

The most common sites are the ovaries, posterior cul-de-sac, uterosacral ligaments, posterior broad ligament, and anterior cul-de-sac. The uterine serosa, rectovaginal septum, cervix, vagina, rectosigmoid and bladder are less frequent locations.

Clinical Manifestations

Endometrosis is characterized by cyclical pain, usually beginning prior to menses. Deep dyspareunia and sacral backache with menses are common.

Infertility is a frequent consequence of endometrosis. Premenstrual tenesmus or diarrhea may indicate rectosigmoid endometrosis. Cyclic dysuria or hematuria may indicate bladder endometrosis.


Tender nodules are often palpable through the posterior vaginal fornix on bimanual examination and along the uterosacral ligaments on rectovaginal examination. Ovarian enlargement, fixation of the adnexal, pelvic pain, retrodisplacement may also be detected.

Ultrasound may identify adnexal masses. Endometrosis can be definitively treated with laparoscopy.