Endometriosis Symptom Checklist

This page intentionally does not assign points, a probability, or a low/high band. No validated bedside point score supports those outputs for endometriosis.

Medically reviewed by Dr. Taimoor Asghar, physician.

What endometriosis is

Endometriosis is a chronic, estrogen-dependent condition in which tissue similar to the lining of the uterus grows outside the uterus. These ectopic deposits, called lesions, are most often found in the pelvis: on the ovaries, the fallopian tubes, the uterosacral ligaments, the broad and round ligaments, the pouch of Douglas, and the rectovaginal septum. They can also appear on the bowel (particularly the rectosigmoid colon), the bladder and ureters, and, rarely, in distant sites such as the lungs or surgical scars. Like the uterine lining, the lesions respond to the menstrual cycle: they bleed, become inflamed, and heal with scarring and adhesions, which is why the pain is often cyclical at first and can become constant as the disease progresses.

Why diagnosis typically takes 7 to 10 years

One of the most replicated findings in endometriosis research is the long gap between first symptoms and diagnosis. Studies across many countries report average delays of roughly 7 to 10 years. Several forces create this delay. First, period pain is widely normalized: girls are told cramps are simply part of being a woman, so severe pain goes unreported for years. Second, the symptoms overlap with other common conditions, including irritable bowel syndrome, painful bladder syndrome, and ordinary primary dysmenorrhea, which leads to misdiagnosis and years of ineffective treatment. Third, symptoms frequently begin in adolescence, when both patients and clinicians may attribute them to immature cycles rather than disease. Fourth, the definitive test is laparoscopy, an invasive surgical procedure that doctors and patients understandably postpone while trying less invasive options.

How this estimator works

The symptom factors: what the evidence says

Subfertility: the strongest clinical signal

Menstrual history: menarche, cycle length, and flow

Three questions cover menstrual history, and they reflect the oldest and most replicated theme in endometriosis epidemiology: greater lifetime exposure to menstruation is associated with higher risk. The leading explanation is the retrograde menstruation theory, which holds that menstrual fragments flow backward through the fallopian tubes into the pelvic cavity, where they implant, proliferate, and trigger chronic inflammation. Under this theory, anything that increases the number or volume of menstrual episodes, early menarche, short cycles, heavy or prolonged bleeding, should raise risk, and the epidemiologic data broadly agree.

Parity: why having given birth is associated with lower risk

Family history: the strongest single risk factor

Body weight and other associated factors

Other factors appear in reviews but are not part of this estimator, either because the evidence is inconsistent or because they are not useful for self-assessment. Smoking has been reported as both increasing and decreasing risk in different studies. Alcohol intake of at least 10 grams per day appears in some risk-factor lists, and taller stature and low birth weight have been implicated in some but not all studies. A few reviews mention a possible association with naturally red hair through pigmentation-related pathways, but this is far from established. This estimator sticks to the eleven factors with the most consistent published support, and says plainly which it leaves out.

What does evaluation involve? The ESHRE 2022 guideline recommends that clinicians use imaging, ultrasound or MRI, in the diagnostic work-up, while being aware that a negative finding does not exclude endometriosis, particularly superficial peritoneal disease. When imaging is negative or empiric treatment fails, the guideline recommends considering laparoscopy for diagnosis and treatment, with lesions confirmed by histology. Before your appointment, it helps to arrive with specifics: when the pain started, how it relates to your cycle, which activities it interrupts, and any bowel, bladder, or fertility symptoms. The guideline notes that while symptom diaries and questionnaires have not been proven to shorten the time to diagnosis, they complement history-taking by objectifying pain and help you demonstrate your symptoms clearly. Empiric hormonal treatment is sometimes offered before surgery, and the choice between medical management, surgery, and fertility planning is individual, which is exactly why the conversation with a clinician matters more than any score.

Worked example

Sources

1. Becker CM et al. ESHRE guideline: endometriosis. Human Reproduction Open. 2022;2022(2):hoac009. The guideline development group recommends considering endometriosis in individuals presenting with dysmenorrhea, deep dyspareunia, dysuria, dyschezia, painful rectal bleeding or hematuria, shoulder tip pain, fatigue, and infertility, and notes that evidence to predict endometriosis from symptoms alone is weak and incomplete.
2. Buck Louis GM et al. Risk factors associated with endometriosis: importance of study population for characterizing disease in the ENDO Study. American Journal of Obstetrics and Gynecology. 2011. Adjusted odds ratios: infertility history 2.43 (operative cohort) and 7.91 (population cohort), dysmenorrhea 2.46, pelvic pain 3.67, parity 0.42, BMI 0.95 per unit.
3. Simpson JL et al. Genetic basis of endometriosis. American Journal of Obstetrics and Gynecology. 1980. First formal genetic study: 6.9 percent of first-degree relatives affected versus about 1 percent of control relatives; 7 percent recurrence risk counseled for first-degree relatives.
4. Malinak LR et al. Heritable aspects of endometriosis. Clinical characteristics of familial versus sporadic cases. 1980. Familial cases more likely to involve severe (stage III to IV) disease.
5. Nnoaham KE et al. Meta-analysis of 18 case-control studies on age at menarche and endometriosis risk: early menarche slightly increased risk (cited in Saridogan E. Adolescent endometriosis. European Journal of Obstetrics and Gynecology and Reproductive Biology. 2017).
6. Vitonis AF et al. World Endometriosis Research Foundation EndoCost Study and Nurses Health Study II analyses: women with endometriosis had lower BMI (about 1.9 kg per square meter lower than controls) at diagnosis and historically.
7. Shafrir AL et al. Risk for and consequences of endometriosis: a critical epidemiologic review. Best Practice and Research Clinical Obstetrics and Gynaecology. 2018. Prevalence of about 10 percent of women of reproductive age.
8. World Health Organization. Endometriosis fact sheet: the condition affects roughly 10 percent (190 million) of reproductive-age women and girls globally.
9. Nnoaham KE et al. Development of a symptom-based tool to predict endometriosis based on the WERF EPHect multicenter data. Human Reproduction. 2012. Symptom-based prediction model; narrative reviews report an area under the ROC curve of 0.683 and sensitivity 83 percent with specificity 76 percent, illustrating the limits of symptom-based prediction.
10. Eskenazi B et al. 2001; Forman RG et al. 1993; Hsu AL et al. 2010 (as cited in the ESHRE 2022 guideline): severe dysmenorrhea predictive of endometriosis, relative risk 1.7 in a prospective laparoscopy cohort.

Frequently asked questions