Well, definitely, it can start in adolescence, so we need these young women to be aware of what the signs and symptoms are.
Number one, it is pain: pelvic pain, pain with your periods, pain if they are having intercourse and pain with regard to bowel function and to ovulation. It can also be associated with heavy bleeding and irregular bleeding.
If we can get this early—and treat it early and think about it early—the gatekeeper is the family physician. Many family physicians don't have time and they normalize this: “Oh, this is just what happens to girls, so suck it up, buttercup.”
You need to listen, because the family doctor or somebody in emergency may have said that you can take NSAIDs and that would help. Sometimes it helps a bit, but it doesn't help that much. If in three months you're taking your initial NSAIDs along with even more serious pain medication, then the physician should think about it. Could this be endometriosis? Should they examine this patient, which they often don't do? Might that patient need diagnostic imaging like ultrasound?
It can also be asymptomatic, which is difficult. When you see this young woman—not the same one, another one—in your infertility practice and you do all of the workup for her and then do maybe a diagnostic laparoscopy, and oh my goodness, you see that she has a pelvis that may not be full of endometriosis but may be at the beginning of endometriosis.
It is pain: pain, pelvic pain, which eventually turns into chronic pelvic pain, but that can take quite a while depending on the serious nature—