New 5-Minute Screening Tool for Endometriosis Detection

A five minute screening questionnaire for the identification of women at risk of endometriosis and early diagnosis has been developed. The questionnaire can be used in primary care and adolescent medicine. It enables the calculation of a risk score based on the risk factors for endometriosis and symptoms experienced by the woman. The score can inform clinicians’ decisions about the need for specialist assessment and counselling, first line treatments or appropriate referral.

Why It Matters

Endometriosis is common, but diagnosis is often delayed

For millions of women worldwide, endometriosis is a disabling and dehabilitating condition for which a definitive diagnosis can be difficult to establish in a timely manner. Endometriosis is a medical and surgical condition in which tissue similar to the lining of the uterus (endometrium) is found elsewhere in the body. In many cases, the external endometrial lesions can cause marked symptoms and significant pain. In contrast, in many cases, the woman with considerable disease may have minimal or no symptoms. This unpredictability is a major reason for the underdiagnosis of endometriosis.

The nature of the symptoms of adolescents and teenagers can lead to a delay in diagnosis. Common complaints of painful periods are expected in the teenage years and initial management with pain relief, application of heat and time may seem sufficient. It is not until the pain worsens, occurs at times other than during the menstrual period, and interferes with normal daily activities such as school, sleep, exercise, leisure activities, and relationships that a girl seeks help for what she perceives to be chronic and distressing illness. The symptoms are often present for several years before proper evaluation and diagnosis occurs.

Symptoms overlap with other conditions

Endometriosis can be delayed in diagnosis due to the similarity of symptoms with more common conditions. However, in contrast to many other gynecologic conditions, endometriosis is not initially managed by a gynecologist. Common and often intermittent symptoms of endometriosis include pelvic pain, abdominal pain and bloating, constipation, diarrhea, nausea, urinary frequency, lower back pain, painful sexual activity, and heavy or irregular menstrual bleeding. These symptoms also suggest a number of other conditions, such as bowel disorders (e.g., IBS), urinary conditions (e.g., urinary tract infections), ovarian cysts, pelvic inflammatory disease, fibroids, and primary dysmenorrhea. Women and health care providers therefore often mistakenly attribute the symptom(s) related to the menstrual cycle to another condition and provide management for conditions involving the gut or bladder in different specialty services before the pattern of symptoms is recognised as related to the woman’s menstrual cycle.

This brief screening tool helps clinicians identify the pattern that matters most for women: pain related to menstruation and other pelvic symptoms that occur cyclically over time. It guides the clinician in asking key clinical questions such as: How does the pain affect activity, how often does the woman take pain medication for this symptom, and is there a first degree relative with endometriosis.

Early diagnosis can protect your quality of life and help you achieve your fertility plans.

Early identification and treatment of pain is therefore crucial to avoid serious and damaging effects that pain can have on an individual. Chronic pain can lead to insomnia and fatigue, cause significant disability limiting activities of daily living, restrict participation in work or school, and cause numerous other problems. Pain patients are often frustrated and report feeling ill understood by their doctors, family, and society at large. Simple relief comes from knowing a person and their pain are believed.

Early diagnosis also provides the opportunity for timing discussions about fertility with women. Although endometriosis is not synonymous with infertility, some women with endometriosis will experience infertility. A screening tool is not intended to predict a woman’s ability to get pregnant, but it can help inform the screening process in several key ways: to help inform discussion with women about the likelihood of achieving levels of symptom control that they find important, to discuss reproductive options, and to timing evaluation and monitoring for potential fertility issues as they relate to the woman’s reproductive goals.

What the “five-minute” tool adds in real-world practice

A short screening tool is only as good as the screening. Ideally it should be quick and reliable rather than precise. The new screening approach utilises a simple questionnaire-based tool that can be used within the time constraints of short visits where clinicians are juggling several issues in the patient’s care. It enables a triage decision to be made and prevents a patient who clearly needs more assessment and treatment than a brief consultation allows from being sent home with stronger pain relief.

It is also important to remember that screening scores are not diagnoses. Clinical judgment should not be supplanted by a score. A high score should indicate that further evaluation is warranted. A low score should not preclude further evaluation for a person with severe symptoms or with multiple red flags. The purpose of screening is to streamline the process to evaluation, decrease unnecessary return visits without progress, and increase the use of evidence-based treatment for symptoms sooner.

Who It Affects

Patients, especially adolescents and young adults

The new and improved features benefit the patients, primarily the adolescents and reproductive-age women with symptoms of menstrual pain or other pelvic symptoms affecting their lives. Most patients develop these symptoms around the time of their first menstrual period. Many do not know how to describe their symptoms or manage their illness. This patient education module uses a standardized questionnaire that guides the adolescent patient in describing the most severe pain experienced, the extent to which the pain affects her, and how often she experiences pain.

Women who experience heavy bleeding, painful periods or frequent pelvic pain may benefit from this screening tool. This test is particularly helpful for women with pain that is not restricted to the first day of bleeding, pain that is increasing or interfering with activities such as school, work or recreation. All women with these symptoms, including those who have a normal physical examination and medical evaluation, may benefit from this test.

People with family history or higher risk patterns

A history of endometriosis in first degree relatives is known to increase the risk in females. This tool helps to identify such patients who may otherwise be overlooked. Many patients do not know of a mother, sister or other close relative who suffers from endometriosis. Asking this question will help identify important clinical history that may indicate an earlier referral or indeed closer follow up.

Screening somatic patients for conversion symptoms can be useful in patients with chronic pelvic pain and repetitive medical utilizers. Even after common diagnoses have been ruled out with typical treatments that relieve most patients with somatic pain (e.g., pain medications over the counter for many), disability can be significant. The screening score can provide further evidence that this patient’s pain needs a more complete assessment rather than continued reassurance that no underlying pathological cause for pain exists.

This leaflet is intended for use by all health professionals.

This flow chart and corresponding Health Record are most likely to be used by healthcare providers who first encounter young girls and women complaining of menstrual pain including primary care physicians and school health providers. These providers would include family physicians and pediatricians, as well as nurse practitioners and physician assistants. They will use this tool to briefly triage, record information, and make referrals when indicated. School nurses and other school health providers would also find this useful.

Healthy teens programs aim to support young people with physical changes as they grow and to help them understand what is going on in their bodies. Healthy teens programs can also support young people and their families to have discussions about a range of sensitive topics, including communication around relationships. Many cultures stigmatise a number of conditions that affect women including menstrual pain. This, and other reasons, mean that many young people may experience embarrassment, fear or worry when they first get their period, and fear or worry that others will think poorly of them. A scripted screening can “take the sting” out of health issues and their associated discussions, and enable workers to easily ask the odd question about issues such as pain, bleeding, bowel symptoms or sexual pain.

Specialists, imaging services, and health systems

Downstream sectors that may be affected include gynaecologists and pelvic pain specialists; Departments of Imaging and multidisciplinary pain clinics. Early diagnosis of pelvic pain is likely to result in the referral of younger women, including teenagers, and planning will be required to prevent simply passing over the waiting list from primary care to specialist units.

These are groups or organisations that will be affected by the introduction of the screening test either during implementation research or post-licensure. Payers and those involved in policymaking within the healthcare system will be affected how health technologies including Xpert MTB/RIF are utilised in organised screening program. Health systems will need to plan for training primary care health workers, referral pathways and policies around programmes of screening to define what are appropriate boundaries of coverage. Xpert MTR/RIF has the potential to increase access to effective screening but could also potentially create unintended bottlenecks.

What Changes

What the new screening tool looks like**

The new five-minute tool uses six short questions and turns “yes” responses into a simple risk score that can support referral decisions. The questions focus on common endometriosis-related patterns: frequent pelvic pain, whether treatment has been sought for pelvic pain, use of pain medication for pelvic pain, heavy menstrual bleeding, painful periods, and a family history of endometriosis. Each item contributes to an overall score that ranges from low to higher risk.

In practice, the tool works best as an add-on to routine care, not as a standalone test. It can be used during adolescent well visits, sports physicals where menstrual concerns arise, visits for painful periods, and appointments for pelvic pain or heavy bleeding. The goal is not to label a patient, but to identify who may benefit from a clearer plan and earlier escalation of care.

How primary care can use the score safely**

Screening should trigger a structured next-step pathway that includes symptom relief, basic evaluation, and clear follow-up. A practical approach in primary care often includes:

• A focused menstrual and pain history, including functional impact (missed school or work, sleep disruption, activity limitation).
• A pregnancy test when pregnancy is possible, especially if bleeding patterns change or pain is new.
• Assessment for anemia if heavy bleeding is present, including fatigue, dizziness, or low exercise tolerance.
• Consideration of other causes of pelvic pain based on age, sexual activity, infection risk, and urinary or bowel symptoms.
• A trial of first-line symptom treatment with clear instructions and a defined review timeline.

Unlike other aspects of practice, for chronic headaches and migraines, diagnosis often follows treatment rather than precedes it. Once symptoms are identified as suggestive of headaches, and no major red flags are present, evidence-based treatment can and should be initiated while diagnostic studies are pursued.

What “earlier treatment conversations” can include

Early discussion of non-surgical options for infertility is important and should be individualized based on the couple’s goals and medical safety. A list of first-line options might begin with

• Nonsteroidal anti-inflammatory drugs used correctly (dose and timing matter) for period-related pain.
• Hormonal suppression options, such as combined hormonal contraception or progestin-based methods, when medically appropriate.
• Education on tracking symptoms, identifying triggers, and recognizing patterns tied to the cycle.
• Supportive measures like heat therapy, sleep strategies, and graded physical activity if tolerated.
• Discussion of pelvic floor physiotherapy or pain-focused supports for patients with chronic pelvic pain features.

For children and their families it is important to know that no one has to suffer from severe pain. It is important to frame the issue in a positive light for the children and families, emphasizing that with pain and anxiety management your child will be able to continue attending school and participating in all of the activities, sports and hobbies that are important to them. Additionally, it is important to prevent further sensitization of pain and to reduce the number of visits to the Emergency Department for pain that can be managed.

Referral and imaging: what to expect

A higher screening score indicates that referral should occur earlier in a woman’s history of complaint of symptoms of endometriosis. However, also consideration should be given to the severity, progression and impairment of the woman’s symptoms. Women with symptoms of increasing pain, between episodes of pain, additional symptoms such as bowel or bladder symptoms or endometriosis related problems requiring specialist advice should be referred to a gynecologist, pelvic pain clinic or a doctor experienced in the management of endometriosis.

Imaging is often used in the diagnosis and management of women with suspected endometriosis. Importantly, normal initial imaging does not exclude the diagnosis. Ultrasound is particularly useful in demonstrating ovarian endometriomas, and with increasing operator experience, evidence of deep endometriosis can also be identified. Superficial lesions are generally harder to demonstrate, therefore a symptom-based screening tool could be useful in identifying women at risk of endometriosis, particularly when initial imaging is normal.

Many individuals can be diagnosed on the basis of clinical features and appearance alone. However, some cases require further diagnostic evaluation. The approach to diagnosis may incorporate analysis of the patient’s medical history and clinical features as well as physical examination. Depending on the clinical situation, therapy, and patient preferences, some individuals may also require diagnostic imaging such as MRI or ultrasound, or even surgery.

In addition to obtaining reliable and accurate analytical results, it is also important to consider methods to mitigate any potential harm, whether it results from a false positive or false negative. In a previous article, we discussed methods to mitigate the effects of false positives in laboratory testing, and in this article, we will continue to discuss methods for mitigating false negative results.

A false negative is defined as a result that states

While easy to use, it is very important that patients are not scared or worried before testing. The results could be explained in a positive light and the patient reassured that they will be informed of any abnormal results. The test result could be explained to the patient and family members as indicating a “higher likelihood of endometriosis”. They need to understand that a positive test result indicates that the clinician wants to look more closely at the pelvis for possible endometriosis lesions, and that most of the time a diagnosis of endometriosis does not require surgery and can be managed with medication and supportive measures.

A low risk score on a screening tool does not necessarily mean that a patient with severe symptoms of endometriosis or other serious illnesses should not receive an evaluation and appropriate treatment. Some women with low risk scores may have endometriosis or another serious condition that requires medical care. As a result, patients with severe, disabling, progressive symptoms such as extreme pelvic pain or other signs of illness should not be denied a comprehensive evaluation solely based on a low risk score.

Equity and access: making screening work for everyone

As screening becomes better at detecting cases, it is critical that timely access to specialists is in place to ensure timely diagnosis and treatment. Ensuring that equity planning is integral to the design and implementation of the screening program is also critical. While individuals living in rural settings and those who are uninsured or otherwise under-served may face vulnerabilities such as delays to diagnosis, lack of access to specialists and uneven access to imaging and/or medication for treatment, our experience suggests that with smart referral pathways, effective telehealth triage, and accessible and affordable first line treatments, avoidable harm can be averted.

Schools and community groups can play a role in ensuring that young women undertake early care seeking for problems that affect them by ensuring that girls and young women understand that severe abdominal pain at the time of menstrual cycling is not “normal”. This can help girls to recognise that they are experiencing severe period pain early on and to effectively describe their symptoms to others.

How clinicians can implement it in five minutes

• Pre-visit intake: patient completes the six questions on paper or a tablet in the waiting area.
• Clinician review: score is reviewed alongside a brief pain and bleeding history.
• Action plan: start symptom management, order basic tests if indicated, and decide on imaging or referral based on score plus clinical context.
• Follow-up: set a time window to reassess symptoms and response, and escalate if not improving.

Though practiced in busy clinics, the tool can be integrated consistently into practice without adding time to consultations.

Documenting the patient’s condition can serve as a means to prevent re-telling the same story to different healthcare providers and to improve the continuity of care. Recording the music and also including a brief description of the effect / how it functions on the patient allows for quick triaging by specialists as well as empowering the patient to better describe their symptoms to healthcare providers.

References:

https://www.ncbi.nlm.nih.gov/books/NBK567777/