Endometriosis can be suspected
- In 50% of women with pain or infertility
- in 80% of women with severe pelvic pain
- in 20% of women with heavy bleeding
- and in some women because of clinical exam or imaging
Endometriosis can cause pain
- deep endometriosis ++++ severe pain in 95%
- cystic ovarian endometriosis +++ pain for in 80%
- superficial endometriosis + pain in 50%; no pain in 50%
- other endometriosis lesions have variable symptoms
Endo can cause Infertility
- +++ for cystic ovarian endometriosis
- + for typical and deep endometriosis
- no effect (?) of subtle or microscopical endometriosis
- other forms as adenomyosis - pockets : decreases fertility variably
Conclusion 1
- 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, are weakly associated . eg abnormal or heavy bleeding, bowel symptoms or bloating.
Endometriosis associated pain?
- dysmenorrhea
- chronic pain
- deep dyspareunia in deep endometriosis or cystic ovarian endometriosis
Where pain: see images
Generally 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 together with dyschezia or menstrual blood loss on the stools or cyclic diarrhea and/or constipation .
- Urinary symptoms. Frequency, urgency, bladder pain, and occasionally bloody urine may occur when endometriosis has involved the bladder.
Clinical exam
- not useful for superficial Endometriosis (occasionally felt as shots)
- Cystic ovarian Endometriosis. Only larger cysts are diagnosed clinically.
- Deep Endometriosis: less than half of the large lesions. Important is the importance of a clinical exam during menstruation
- A negative clinical exam cannot exclude endometriosis
Conclusion 2
- 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,
Cat scan and colonoscopy
- only indicated for very large deep endometriosis nodules.
MRI
- 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
Ultrasound
- is the method of choice to diagnose cystic ovarian endometriosis
- cannot diagnose superficial endometriosis
- the predictive value for deep endometriosis is some 90% if experience and a larger nodule, but limited for smaller lesions
- For a detailed discussion on the pitfalls of ultrasound read
The decision to do a laparoscopy is a difficult clinical decision
- 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
- 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 much belief in imaging can result in (unnecessary) bowel resections
Why is the delay in diagnosis long.?
- too little experience to suspect Endometriosis : we only recognize what we know.
- the non-surgeons exaggerate the use of medical treatment
- endometriosis surgery is difficult and pelvic surgeons are rare.
- The erroneous belief that all endometriosis can be diagnosed by imaging
- 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.
Mistakes
- Medical treatment for long periods without a diagnosis : endometriosis can keep growing.
- medical treatment without follow-up
- Superficial coagulation of typical lesions since often incomplete if deeper.
- 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 or preventable rectum resection for recto-vaginal endometriosis
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