Pelvic pain, pelvic mass, alteration of menses, and infertility are typical. Some women with extensive endometriosis are asymptomatic; some with minimal disease have incapacitating pain. Dyspareunia and midline pelvic pain before or during menses, particularly beginning after several years of pain-free menses, may develop. Such dysmenorrhea is an important diagnostic clue.

Implants on the large intestine may cause pain during defecation, abdominal bloating, or rectal bleeding during menses; those in the bladder may cause dysuria, hematuria, suprapubic pain, or a combination during urination. Implants on the ovary can form a cystic mass that is 2 to 10 cm and localized to an ovary (endometrioma); those on adnexal structures can form adnexal adhesions, resulting in a pelvic mass. Occasionally, an endometrioma ruptures or leaks, causing acute abdominal pain and peritoneal symptoms. Nonpelvic endometriosis can cause vague abdominal pain.

Pelvic examination may be normal, or rarely, lesions can be seen on the vulva or cervix or in the vagina, umbilicus, or surgical scars. Findings may include a retroverted and fixed uterus, enlarged ovaries, fixed ovarian masses, thickened rectovaginal septum, induration of the cul-de-sac, or nodularity of the uterosacral ligament.