Dr. Steve Vasilev, MD, Gynecologist, Endometriosis Surgeon*:

The answer to this should be highly individualized and not standardized, although a full evaluation should contain questions and examination points that cover all the required bases. What this means is it depends on a lot of factors including whether or not you already have a correct diagnosis or not. Is it endo? Is it something else? Is it unknown? The approach would likely be different in each case.

To answer this question, I’ll assume that endometriosis is already diagnosed based on prior surgery or at least strongly suspected. But it’s VERY important not to have tunnel vision about this. Lots of diseases and syndromes can cause pelvic pain and it is not all endometriosis-based. On the other hand, non-endo conditions involving other organs (urinary and intestinal) can be strongly associated with endo and cause part of the pain. So, the pain may be due to a number of reasons, all of which need to be sorted out as best as possible and may involve additional consults with others, such as neurology and pelvic floor therapy.

The following is a list of questions you may be (or should be) asked. As far as examination is concerned, this really depends. I personally favor a virtual (or in-person) visit first and avoid an examination altogether because this lessens the anxiety about that part when you are meeting your potential surgeon. Planning for further testing, including possible examination, is then more relaxed (it’s a version of “baby steps”). So you can request that if it is more comfortable for you. Having said that, there is an overview below that covers some of the exam basics as well, and the reason for each part.

The consultation should start with a detailed history that includes questions about urinary, intestinal, gynecologic, musculoskeletal, as well as sexual and psychosocial symptoms and history. Again, all bases should be covered that might be contributing. If you think something can be related to your pain and is not being asked about, bring it up!

Beyond the general questions, for each significant part think about the details:
• Is the pain sharp or dull, achy, intermittent, and so on?
• Is there anything that provokes the pain?
• Pain with sex or bowel movements or urination?
• Is there cyclic bleeding from the rectum?
• What about positions where the pain might increase?
• Is it localized or does it radiate, like down the leg?
• Is it only during your period or all the time?
• Is there pain soon after eating?
• Are there associated symptoms like nausea?

Some questions are related to lifestyle and habits and may delve into deeply personal history:
• Do you sleep well?
• Fatigue? Anxiety? Fears?
• Are you depressed?
• What is going on in your life that might contribute to pain?
• Was there any abuse?
• If on pain or psychoactive medications, how much of what are you taking?

The above is just an example of the directions that might be explored. The devil is in the details, so 100% honest and well-thought-through answers can make the difference.

As far as the examination is concerned, whether it be the same day or scheduled later, it should be both general and focused. So, no matter where the location in or outside the pelvis, are there pain trigger points? Often both sharp and dull objects are used to see what might trigger the pain. Some nerve paths can be traced and others not. Different positions might provoke pain, like flexing the abdominal wall or raising legs against resistance. Are there any hernias that can be palpated? Depending on symptoms, a general exam can be quite detailed and beyond a regular checkup exam because they are trying to pinpoint the pain trigger locations. This can have a bearing on treatment and surgery and what consultants might need to be involved.

As far as a pelvic examination is concerned, it will likely be longer and more detailed than what you might experience during a Pap smear routine exam. Using cotton swabs and palpation using hands and fingers the examiner may try to reproduce pain to determine if it is vulvar, paravaginal, cervical, bladder-base, pelvic floor (and exact location), and so on. A vaginal speculum exam can help determine if there are any abnormal areas in the vagina or on the cervix, including visible endo or suggestion of adenomyosis. Finally, a rectal exam may also be used to help determine the exact location or possible anorectal origin of the pain.

All of the above may help guide whether or not imaging, like ultrasound or MRI, would help. Keep in mind, the only way to accurately diagnose endometriosis is through surgery and biopsies, with excision of all visible lesions when they are uncovered. So, history, exams, imaging, and blood testing, can all suggest endo but cannot prove it with the current state of the art. Soon, we will likely have accurate molecular testing, but not yet.

Having said all of the above, in many cases, an examination may not be very helpful and most, if not all, of the information required, can be obtained from detailed history and imaging tests. There would likely be disagreement on this between doctors, but I’m just suggesting that everyone is different and the approach should be personalized. Going forward towards pelvic floor therapy, that goes beyond a general diagnostic exam and evaluation by your surgeon. An abdominal and pelvic exam in this setting would definitely be the most detailed in order to specifically plan the pelvic floor therapy and is a separate discussion.

*This is not medical advice and is aimed for informational use only. Please contact the doctor’s office or consult with your doctor for any medical questions.