Immunomodulatory drugs inhibiting pelvic inﬂammation associated with endometriosis may offer new approaches to medical treatment and can be studied in these models (149–153). In a consensus workshop following the 10th World Congress on Endometriosis in 2008, it was agreed that multidisciplinary expertise is required to advance our understanding of this disease, and 25 recommendations for research were developed (154).
Clinical Presentation Endometriosis should be suspected in women with subfertility, dysmenorrhea, dyspareunia, or chronic pelvic pain, although these symptoms can be associated with other diseases.
Endometriosis may be asymptomatic, even in women with more advanced disease, (i.e., ovarian endometriosis or deeply invasive rectovaginal endometriosis).
Risk factors for endometriosis include short cycle length, heavier menstruation, and longer ﬂow duration, probably related to a higher incidence of retrograde menstruation (45,155,156). Patient height and weight are positively and negatively, respectively, associated with the risk of endometriosis (157).
Endometriosis can be associated with significant gastrointestinal symptoms (pain, nausea, vomiting, early satiety, bloating and distention, altered bowel habits). A characteristic motility change (ampulla of Vater–duodenal spasm, a seizure equivalent of the enteric nervous system, along with bacterial overgrowth), is documented in most women with the disease (158). Women of reproductive age with endometriosis are not osteopenic (159).
The average delay between onset of pain symptoms and surgically confirmed endometriosis is quite long: 8 years or longer in the United Kingdom and 9 to 12 years in the United States (160). Similar durations were observed in Scandinavia and in Brazil (161,162). A delay in diagnosis of endometriosis of 6 and 3 years in women with pain and women with infertility, respectively, was reported. Over the past two decades, there was a steady decrease in the delay in diagnosis and a decline in the prevalence of advanced endometriosis at first diagnosis (163). Patient awareness of endometriosis was increased. Many patients’ quality of life is affected by pain, emotional impact of subfertility, anger about disease recurrence, and uncertainty about the future regarding repeated surgeries or long-term medical therapy and its side effects (164).
Endometriosis should be perceived as a chronic disease, at least in a subset of highly symptomatic women, and quality-of-life issues should be evaluated using reliable and valid questionnaires (165).
Pain In adult women, dysmenorrhea may be especially suggestive of endometriosis if it begins after years of pain-free menses. Dysmenorrhea often starts before the onset of menstrual bleeding and continues throughout the menstrual period. In adolescents, the pain may be present after menarche without an interval of pain-free menses. Evidence suggests that absenteeism from school and both the incidence and duration of oral contraceptive use for severe primary dysmenorrhea during adolescence is higher in women who later develop deeply infiltrative endometriosis than in women without deeply infiltrative endometriosis (166).