Endometriosis -> pain
- deep endometriosis ++++ severe pain in 95%
- cystic ovarian endometriosis +++ pain for in 80%
- typical endometriosis + pain in 50%; no pain in 50%
- subtle endometriosis + pain in 50%; no pain in 50%
- other endometriosis lesions have variable symptoms
- 50% of women have endometriosis
- if very severe pain: more cystic and deep endometriosis
Endo and Infertility
- +++ for cystic ovarian endometriosis
- + for typical and deep endometriosis
- no effect (?) of subtle or microscopical endometriosis
- other forms
- adenomyosis - pockets : decreases fertility variably
- 50% probability of typical lesions
- all other causes remain possible
- when pain or infertility : 50% of women have endometriosis
- !! Localization and radiation can suggest cystic ovarian or deep endometriosis
- all women with pain or in fertility are suspected to have endometriosis
- Other symptoms, often quoted on web-sites and lay press, have a weak association . eg abnormal or heavy bleeding, bowel symptoms or bloating.
- Generally dysmenorrhea
- sometimes chronic pain
- deep dyspareunia in deep endometriosis or cystic ovarian endometriosis
- hypogastric pain generally radiating to the back ;
- radiation in the anterior part of the upper leg suggests cystic ovarian endometriosis
- perineal pain is pathognomonic for deep endometriosis
- dyschezia, i.e. bowel cramps and pain during menstruation, or menstrual blood loss on the stools. Also, cyclic diarrhea and/or constipation can be suggestive.
- Urinary symptoms. Frequency, urgency, bladder pain, and occasionally bloody urine may occur when endometriosis has involved the bladder.
- Endometriosis invading the ureter causing obstruction cause ureter pain.
- not useful for Subtle and typical Endometriosis (occasionally felt as shots)
- Cystic ovarian Endometriosis. Only larger cysts are diagnosed clinically.
- Deep Endometriosis: only half of the large lesions. Important is the importance of a clinical exam during menstruation
A negative clinical exam cannot exclude endometriosis
- is the method of choice to diagnose cystic ovarian endometriosis
- cannot diagnose superficial endometriosis
- the predictive value for deep endometriosis is only 90% if experience and a larger nodule, but limited for smaller lesions
- For a detailed discussion on the pitfalls of ultrasound read 2021_pk_pitfalls-US
- an endometrioma is diagnosed in US but malignity cannot be excluded.
- A cystic corpus luteum causes false positives.
- Ultrasound imaging needs to be interpreted in close collaboration with the surgeon.
- Malignancy? some 3% of the endometrioma’s are malignant in women after menopause,
These exams are only useful as a preparation for surgery but limited for diagnosis.
- Cat scan and colonoscopy can detect very large deep endometriosis.
- MRI is overused especially for pain in general.
- Not useful for superficial endometriosis.
- No added value for cystic ovarian endometriosis.
- For deep endometriosis: similar to ultrasound without added value
- MRI is useful for diagnosing adenomyosis, as a thickened junctional zone, or as a focal adenomyosis
- The first decision, is whether a laparoscopy should be planned
- This decision is clear when a deep nodule or a large cystic ovarian endometriosis are diagnosed.
- The decision is clinical in all other women with pain and/or infertility. Ultrasound imaging alone is not an indication (although often misused).
- The second decision, when a laparoscopy is planned, is which additional exams should be done and how surgery should be planned
- If deep endometriosis is not suspected a bowel preparation is not necessary and surgery can be done as day care.
- If deep endometriosis is suspected, additional exams as contrast enema and IVP, and a bowel preparation before surgery are mandatory. IVP diagnoses hydronefrosis i.e. whether ureter stents are necessary. A contrast enema diagnoses bowel occlusion. The degree and length of occlusion predict the difficulty of surgery, and thus for the informed consent.
- Laparoscopy remains the gold standard for diagnosis.
- The usefulness of imaging to predict surgical difficulty is limited.
- Imaging alone is rarely an indication for a bowel resection
- Too often imaging is used as a alibi to do (unnecessary) bowel resections
Why is the delay in diagnosis long.?
- the gynecologist needs experience to suspect Endometriosis : we only recognize what we know.
- the non-surgeons exaggerate medical treatment to avoid surgery,
- endometriosis surgery is difficult and pelvic surgeons are rare. Less experienced surgeons often prefer to give medical therapy before referring the patient.
- The erroneous belief that all endometriosis can be diagnosed by anything else than by a laparoscopy
- the difficulty of surgery is difficult to predict. Therefore I introduced Oxford that the ex-fellows could perform a diagnostic laparoscopy and judge if they could do the surgery; if not, they refer.
- Medical treatment for long periods without a diagnosis .
- medical treatment without follow-up
- Superficial coagulation of typical lesions since often incomplete .
- Drainage of cystic ovarian endometriosis
- Miss-diagnosis of a cystic corpus luteum
- Destruction of the ovary, by lack of experience.
- Missing Deep endometriosis. or Incomplete excision of deep endometriosis by lack of experience and by fear of complications.
- Unnecessary rectum resection for recto-vaginal endometriosis