By: Dra. Nuria Luna Ramírez, MD, MSc, FACOG Gynecologist with a subspecialty in Advanced Gynecologic Surgery March 2025
Studies point to prolonged intervals of up to 7 to 10 years between the onset of symptoms and the diagnosis of endometriosis.
Primary care physicians can play a critical role in the early identification of endometriosis symptoms. Despite its high prevalence, the condition remains underdiagnosed due to its various symptoms, highlighting the importance of a multidisciplinary approach. In this article, you’ll learn how to identify endometriosis symptoms in your patients, what treatments you can prescribe at the primary care level and what are the indications for referring to a specialist.
It is estimated that endometriosis affects 10% of women of reproductive age worldwide. In Puerto Rico, according to Forquet et al. (2019), the prevalence of endometriosis is 7.4%, which is equivalent to approximately 70 thousand women between the ages of 10 and 50 (2000 Census). This condition is characterized by the presence of endometrial-like tissue outside the uterus, causing inflammation, pain, and the formation of scar tissue, and may also contribute to patient morbidity.
Identify the symptoms for a possible diagnosis, treatment and early referral
In table 1 we list the symptoms your patients with endometriosis may present.
Table 1. Endometriosis symptoms
Chronic Pelvic Pain
This is one of the most common symptoms.
Dysmenorrhea
Pain during menstruation should not be considered normal. If the pain is so severe that it disables the patient or requires the use of drugs to control it, the possibility of endometriosis should be evaluated.
Dyspareunia
Pain during or after sexual intercourse.
Abnormal Uterine Bleeding
Includes excessively heavy periods (menorrhagia) or bleeding between cycles.
Infertility
Endometriosis is associated with an increased risk of problems conceiving. Women who have difficulty getting pregnant should be evaluated for the possibility of endometriosis.
Gastrointestinal Symptoms
Especially during menstruation, patients may experience:
Urinary Symptoms
If the bladder is affected by endometriosis, the following may occur:
If you suspect the presence of these symptoms in your patient, consider these tests for an evaluation:
Detailed medical history - for evaluating symptoms and history related to endometriosis.
Physical exam - especially a pelvic exam, that can help identify painful or abnormal areas in the pelvis that suggest the presence of endometriosis.
Use of imaging exams – includes the transvaginal sonogram, useful for identifying endometriomas (ovarian cysts) and other abnormalities in the ovaries, as well as to rule out other pathologies that may present similar symptoms. Can also use the Magnetic Resonance Imaging (MRI) in cases of suspected deep infiltrating endometriosis, because it provides detailed images of the pelvis and can aid the subspecialist in surgical planning.
Laboratory tests such as a CBC and CA-125 - necessary to rule out anemia. While there is no specific blood test for endometriosis, CA-125 may be elevated in some patients. However, this test is neither specific nor sensitive for endometriosis, as high levels of CA-125 can also be seen in other gynecologic or malignant conditions.
Evaluate primary care level treatment options
Before referring to a specialist, you can prescribe your patient nonsteroidal anti-inflammatory drugs (NSAIDs) and hormone therapy. . This last therapy ex. oral contraceptives, Depo-Provera, Nexplanon, progesterone intrauterine devices, patches, vaginal rings) can be considered if the patient does not have any contraindications. Hormonal therapy helps regulate the menstrual cycle and reduces the proliferation of endometrial tissue, which can relieve pain and other associated symptoms.
Consider referring the patient to a specialist
A timely referral can contribute to improving the quality of life for your patients by minimizing the physical, psychological, and economic impact a diagnosis of endometriosis entails. Consider the indications in Table 2:
Table 2. Indications for referring your patient to a specialist
Severe or Refractory Pain
If the pain is not adequately controlled with initial medical treatment, refer the patient to a gynecology specialist.
Suspected Deep Infiltrating Endometriosis
If you suspect that endometriosis is affecting structures such as the bowel, bladder, or other nearby areas, refer to a subspecialist in advanced pelvic surgery.
Patients with suspected or confirmed endometriosis who wish to conceive and face difficulties in achieving pregnancy, refer to a gynecology specialist.
Surgical Consideration
Refer to a subspecialist in advanced pelvic surgery.
After referring your patient and confirming the diagnosis, it is advisable to maintain open communication with the specialist. Some information the gynecologist should share with you for your patient’s follow up is:
Confirmation of the diagnosis - detailing the definitive diagnosis, which may include the identification of endometriotic lesions by laparoscopy, biopsy or relevant diagnostic imaging (such as an ultrasound or MRI).
Location and extent of the endometriosis - information about the affected areas (ex. ovaries, intestines, bladder, peritoneum, etc.), and whether it is superficial or deep endometriosis.
Recommended treatment - including an anti-inflammatory diet, hormone therapy, analgesics (NSAIDs), and/or surgical treatment.
Referral recommendation to other specialists - whether it is pelvic physical therapy, a gastroenterologist, advanced pelvic surgeon, colorectal surgeon, and/or general surgeon, with a follow-up plan that may include indications for follow-up visits, the need for additional studies or treatment adjustments, and the frequency with which the patient should be re-evaluated.
Endometriosis is a complex condition that requires a multidisciplinary approach for optimal management. Primary care physician intervention in early recognition and appropriate referrals can significantly improve outcomes and quality of life for patients with this condition.
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