Ep 214 Bridging the Gap in Endometriosis Care: Recognition, Risk Stratification, and ED-Initiated Management

February 25, 2026

AI Summary

5 min read

A 24-year-old woman arrives at 2 AM curled on her side, pale, vomiting, with 10-out-of-10 pelvic pain that started with her period. Her heart rate is 118. She has been to the ED twice in the past six months with the same story. Each time, an ultrasound showed a small hemorrhagic ovarian cyst. She was discharged with NSAIDs and told to follow up with gynecology—an appointment she never got. Now she is back, worse than before, and the ultrasound again shows only a small cyst. No torsion. No free fluid. No acute surgical pathology. The pain is still 10 out of 10.

This is the classic endometriosis patient in the emergency department, and as Dr. Jennifer McCall, a minimally invasive gynecologic surgeon, explains, the delay to diagnosis in Canada is seven to ten years, with patients seeing 10 to 12 physicians before receiving a correct diagnosis. The episode, hosted by Dr. Anton Hellman with Dr. Catherine Varner, focuses on how emergency providers can break that cycle—by recognizing the pattern, avoiding misdiagnosis, and initiating first-line treatment.

Why Endometriosis Patients End Up in the ED

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What you'll learn

1 (00:00) **Episode Introduction & Case Presentation** - Host Anton Hellman sets up a classic overnight ED scenario: a 24-year-old woman with severe cyclic pelvic pain, vomiting, and a history of similar visits.
2 (03:21) **Guest Introductions & Clinical Context** - Dr. Catherine Varner (EM) and Dr. Jennifer McCall (MIGS) join; they frame the patient's long ED journey and the risk of diagnostic momentum.
3 (10:07) **Why Endometriosis Patients End Up in the ED** - Long wait times for gynecologic care, lack of outpatient providers comfortable with endometriosis, and patient fear of life-threatening causes drive ED visits.
4 (14:10) **Rare but Dangerous Complications of Endometriosis** - True emergent complications occur in 1-5% of presentations and include bowel obstruction, infected endometrioma, hemoperitoneum, ureteric obstruction, and catamenial pneumothorax.
5 (16:43) **How Endometriosis Differs from Other Recurrent Pain Patients** - Unlike many chronic pain populations, endometriosis has highly effective treatments (hormonal therapy) that can be initiated early.
6 (20:29) **Imaging Clues: Cysts and Endometriomas** - Normal ultrasound does not rule out endometriosis; Canadian hospital imaging standards are not designed for endometriosis mapping.
7 (26:10) **Historical Features That Predict Endometriosis** - Key red flags for secondary dysmenorrhea and endometriosis in the ED.

+ Full timestamped outline available in the app

Show Notes

We walk you through what Emergency Physicians need to know to recognize, risk stratify, and manage endometriosis safely and pragmatically. We answer question such as: When should endometriosis rise to the top of the differential for pelvic pain? How do we distinguish an endometriosis flare from a dangerous endometriosis complication? from Pelvic Inflammatory Disease? Why hemorrhagic cyst the most common misdiagnosis for endometriosis and how can we tell the difference between hemorrhagic cyst and endometrioma? Which hormonal therapy is safe, reasonable and effective to start in the ED? What are the most common life-threatening complications of endometriosis we should be on the lookout for in the ED? How do we discharge patients with suspected endometriosis safely and reduce repeat visits? and many more... Please consider a donation to EM Cases to ensure continued free open access medical education here: https://emergencymedicinecases.com/donation/