OBJECTIVES: To evaluate a clinical examination during menstruation and plasma 
CA-125 concentrations to diagnose deep endometriosis.
DESIGN: Prospective study in 61 women scheduled for a laparoscopy, a 
retrospective study in 140 women with deep endometriosis, and a clinical 
validation study in 16 women with painful pelvic nodularities during 
menstruation.
SETTING: University Hospital Gasthuisberg, a tertiary referral center.
RESULTS: In the retrospective study, deep endometriosis was detected by routine 
clinical examination in only 36% of women. Lesions infiltrating deeper than 15 
mm were detected in 50%. In the prospective study pelvic nodularities were 
detected by routine clinical examination in 4 women but were detected in 22 by 
clinical examination during menstruation. The latter was highly reliable to 
diagnose deep endometriosis, cystic ovarian endometriosis, and cul-de-sac 
obliteration. CA-125 concentrations were higher during menstruation and 
correlated with deep endometriosis and with deep and cystic ovarian 
endometriosis. Nodularities at clinical examination or follicular phase CA-125 
concentrations > 35 U/mL are useful to decide that a bowel preparation should be 
given, achieving a sensitivity of 87% and a specificity of 83%. In the clinical 
validation study, deep endometriosis was found in 14 of 16 women.
CONCLUSION: Clinical examination during menstruation can diagnose reliably deep 
endometriosis, cystic ovarian endometriosis, or cul-de-sac adhesions. This test, 
preferentially combined with a follicular phase CA-125 assay, should be used to 
decide whether a preparation for bowel surgery should be given.