Endometriosis and unexplained musculoskeletal manifestations in reproductive-age women: A narrative review.

Endometriosis, Musculoskeletal Pain, Diagnostic Delay, Extrapelvic Endometriosis, Catamenial Pain, Multidisciplinary Care.

Classically defined as a chronic, recurrent gynaecological disease characterized by progressive pelvic pain, infertility, and/or abnormal uterine bleeding, endometriosis is increasingly recognized for its systemic manifestations. Emerging evidence links the disease to broad inflammatory and neurobiological processes that may account for symptoms extending beyond the pelvis. Not uncommonly, endometriosis may present solely with musculoskeletal (MSK) manifestations, such as diverse pain patterns, muscle weakness, numbness, gait disturbance, or knee weakness, closely mimicking primary orthopaedic or rheumatological disorders. Pain in endometriosis arises through multiple interconnected mechanisms, including direct lesion infiltration, persistent inflammation, peripheral neuromuscular involvement, and central sensitization. Consequently, its clinical spectrum is broad, encompassing nociceptive MSK pain, neuropathic or radicular symptoms, joint-related pain, mass-forming lesions, and widespread nociplastic pain, often with a characteristic cyclical (catamenial) pattern. This represents a significant clinical gap, as affected patients frequently first seek care in non-gynaecological settings such as orthopaedic or rheumatology clinics. Diagnostic delays are common, averaging 5–10 years, during which patients are often managed symptomatically while the underlying aetiology remains unrecognized. The objective of this narrative review is to raise awareness among clinicians and synthesize evidence-based guidance for diagnosing and managing endometriosis-related MSK manifestations. We propose a stepwise diagnostic approach emphasizing careful history-taking for cyclical symptoms, focused physical examination, judicious use of imaging, and early gynaecological consultation. Management should be multimodal and integrated, combining hormonal therapies, surgical excision for refractory lesions, targeted rehabilitation, and pain neuroscience-informed strategies. Ultimately, optimizing outcomes requires MSK clinicians to serve as sentinels, recognizing red-flag presentations and initiating timely multidisciplinary co-management.