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How can endometriosis be diagnosed?

Endometriosis generally affects 3% – 10% of women of reproductive age. There is still no known cause of Endometriosis, women with family history have a higher chance of developing endometriosis. It is also possible that women whose menstruation starts at an early age and other factors such as low body mass index may contribute to higher risk of endometriosis.

Endometriosis is characterized by the presence of endometrial glands and stroma like lesions outside of the uterus which may be found in the peritoneum, ovary, or pelvic region. The lesions may be superficial or present as deep infiltrating lesions. Endometriosis can affect you adversely due to the associated pain, infertility, decreased quality of life, and interfere with your daily life, relationships, and livelihood. It has been observed that there is often a delay of 4 to 11 years from onset of symptoms to diagnosis of endometriosis.

If your physician suspects that you have endometriosis based on your symptoms, you may be referred to a gynaecologist. The gynaecologist will further examine you internally to look for pelvic masses and elicit tenderness.

Not all patients may have physical findings. An experienced gynaecologist may detect tender nodular masses along thickened uterosacral ligaments, the posterior uterus, or the posterior cul-de-sac. Experienced clinicians can predict endometriosis on the basis of history and clinical examination in about 80% cases.

Why is diagnosing endometriosis tricky?
The symptoms of endometriosis are similar to other gynaecological conditions like dysmenorrhea, fibroids, ovarian cysts etc. In most cases, there is an average 10-year delay from the onset of symptoms to the diagnosis of endometriosis. It is often difficult to differentiate dysmenorrhea due to primary and secondary causes. Moreover, patients may not disclose the severity of menstrual pain to avoid drawing attention to themselves or may not realize the seriousness of the condition. Along with that, biomarkers and pathognomonic features are currently absent that could sufficiently diagnose endometriosis.

There are few clinical maneuvers that can be used for physical diagnosis of endometriosis. Physical signs may be completely absent or the large recess behind the cervix may include tender nodules, uterine motion tenderness, a uterus that is tipped backwards, or a lump in the adnexa resulting from endometriomas.

Certain tests may be conducted to find the cause of pelvic pain and tenderness like urinalysis, Pap smear, pregnancy test, vaginal and endocervical swabs. An ultrasonography of the abdomen and pelvis might be carried out to detect an endometrioma, fibroids and ovarian cysts.

What is laparoscopy?
Laparoscopy is the gold standard for diagnosis of endometriosis. It avoids a large abdominal incision. A laparoscope is introduced through a very small incision to view the abdominal organs. The endometrial lesions can be viewed via laparoscopy and smaller lesions (Ovarian cysts, endometrial implants and scars) can be removed at the same time. However, laparoscopic diagnosis for endometriosis is never certain. Certain endometrial growths are hidden from the laparoscopic view. 

The Benefits & Risks of Laparoscopy as a Diagnostic Tool

Benefits Risks
1. Accurate 1. Highly invasive. Higher recovery time.
2. Diagnosis and treatment ability at the same time 2. Risk of Infertility and increase in pain.
3. Useful to rule out other conditions such as cancers. 3. Damage to egg supply if treating on the ovary at the same time
4. Less preferred to ultrasound or physical exam for solely diagnostic purposes

*Collated from different research and review articles.

How do I prepare myself for laparoscopy?
Laparoscopy is preformed under anaesthesia (general or spinal) by a gynaecologist or a surgeon. Since it is a surgical procedure, you will be advised to undergo pre-operative testing to ensure fitness for anaesthesia.

You are advised to remain fasting (not to eat or drink anything) for 8 hours before the procedure. During the procedure the abdomen is inflated with gas to get a clear view. The abdominal wall is pushed away by the gas and the organs and lesions can be seen more clearly. The laparoscope is inserted through a small incision to view the organs and any abnormal lesions (endometrial lesions). One or two additional incisions may be needed to insert more instruments to get a clear picture.

During laparoscopy, endometriosis may be seen as adhesions associated with peritoneal implants, infoldings in the peritoneum, endometriomas and deep infiltrating nodules of endometriosis. 

If the lesions need to be removed, they are excised (cut and removed) or cauterized (using laser beam and electric current). The procedure may take half an hour to 45 minutes (more if the lesions are extensive). After the procedure, the abdominal incisions are closed by suturing.

How long do I need to stay in the hospital?
It depends on the procedure. Laparoscopy can be done as an out-patient procedure. If required, you may stay for a day in the hospital. You need to rest for a few days. You can resume normal activities in 5 -7 days post the procedure.

Do all patients require laparoscopy?
Laparoscopy is done when symptoms are not relieved by the conventional medical treatment. It may also be indicated in patients with severe pain or when the disease is affecting bladder or bowel function. Laparoscopy is useful for management of infertility and for removal of an ovarian endometrial cyst. It is usually not recommended to detect and treat superficial peritoneal endometriosis in infertile women without pelvic pain symptoms.⁽¹⁾

What are the latest methods of diagnosis?
An endometrial biopsy can be obtained during laparoscopy. The tissue removed is sent for histopathology to confirm the diagnosis of endometriosis.

Other than ultrasonography, imaging methods like CT scan and MRI are done for diagnosis of endometriosis. MRI is more accurate but is expensive compared to ultrasound examination.

Certain new blood tests are under investigation. Serum markers for endometriosis will be preferred as they are non invasive. Serum cytokines, matrix metalloproteinases, adhesion molecules, and markers of angiogenesis or inflammation have been investigated. As of now, these tests are not specific and currently undergoing research.

As discussed above, it can be assumed that the gold standard for diagnosis of endometriosis is laparoscopy. Radiological imaging may be recommended after clinical examination. Diagnosis is important as it helps to decide the course of treatment.

References
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5737931/

https://www.ajog.org/article/S0002-9378(19)30002-X/fulltext

https://www.uofmhealth.org/health-library/hw101171

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2880548/