The symptoms of endometriosis
Endometriosis is the most common finding associated with pain in women of reproductive age. It is arguably the most common cause of pain, and it deserves most of the bad press it receives. Endometriosis pain is frequently localized by the patient to the pelvic area that is involved by the disease. Some patients can describe exactly where their disease is by the nature and location of their pain. Since the cul-de-sac, uterosacral ligaments, and posterior broad ligaments are the most commonly involved pelvic areas, many patients experience pain related to irritation of disease in these areas by common bodily functions. Therefore, cul-de-sac and uterosacral ligament endometriosis can be irritated by deep penetration with sexual intercourse, whereas more superficial pain with intercourse is usually not due to the disease.

These lower pelvic areas can also be irritated by stool passing by during bowel movements, so painful bowel movements can occur when these pelvic areas are involved, although usually this pain is primarily related to the menstrual flow. When the rectal wall is involved by endometriosis, the patient may complain of pain with every episode of bowel movement regardless of menses.

We found that pain with each bowel movement regardless of menses - not constipation or diarrhea - is the cardinal sign of rectal endometriosis. The bladder, however, can be involved by extensive endometriosis and the patient will rarely complain of bladder symptoms.

Fibroid tumors
Fibroids (also called "leiomyoma") are accumulations of smooth muscle which arise within the uterine muscular wall. They expand in size somewhat concentrically, like a pearl growing in an oyster. A large fibroid would be the size of a grapefruit or larger. A small fibroid would be smaller than a marble. They can cause uterine cramping between menstrual flows and severe cramping and heavy bleeding with the flow, unless they are hanging off the outside surface of the uterus, in which case symptoms may be absent.

The pain of endometriosis is often described as sharp, burning, or knifelike. It may occur all month long, although exacerbated by the menstrual flow. The notions that endometriosis primarily hurts only during the menstrual flow or that the cardinal symptom is uterine cramps are incorrect.

The cardinal symptoms of pelvic (non-intestinal) endometriosis include a sharp, stinging, burning knifelike pelvic pain which occurs away from the menstrual flow but which may be aggravated by the flow, pain at the top of the vagina with deep penetration during intercourse, and painful bowel movements during menses.

Symptoms not typical of endometriosis
Heavy menstrual bleeding is not a primary symptom of endometriosis and most likely will not be changed with conservative surgery for endometriosis. Other symptoms which are not necessarily suggestive of endometriosis are clitoral pain, leg and groin pain, nausea, fatigue, constipation, diarrhea and bladder discomfort.

When adhesions hurt, they hurt in the place they occur. Patients sometimes use terms such as "pulling" or "stretching" to describe adhesion pain. Adhesion pain would not be expected to vary with the menstrual cycle unless adhesions around an ovary get stretched by the slight growth of a cyst. Many patients with endometriosis have adhesions as well, and it is often not possible to determine whether their pain is due to adhesions or endometriosis.

A word about cramps
If dysmenorrhea (menstrual cramps) is the main symptom, then conservative surgery for endometriosis alone may not improve this symptom, since this is the symptom least likely to respond to conservative surgery for endometriosis. Other conditions can cause painful periods. If endometriosis is the cause, your periods will improve and become less painful. If the cramping is coming from the uterus itself, however, removing endometriosis from areas outside of the uterus will not help this situation.

Two other treatments may help with menstrual cramping: transection of the uterosacral ligaments and presacral neurectomy. These procedures are designed to prevent the nerves from transmitting the cramping sensation and both can be performed through the laparoscope.