Endometriosis and pain
- very very severe pain in deep endometriosis in 95%
- very severe pain for cystic ovarian endometriosis in 80%
- variable pain for typical endometriosis but 50% have no pain
- subtle endometriosis causes pain in some 50%
- other endometriosis lesions have variable symptoms
- 50% of women have typical and or subtle lesions
- 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
- Important is Localization and radiation that suggest cystic ovarian and deep endometriosis
- thus all women with pain or in fertility are suspected to have endometriosis
- Other symptoms, often quoted on web-sites and lay press, have little proven evidence. eg abnormal or heavy Uterine Bleeding. Gastrointestinal symptoms as abdominal bloating or nausea.
Type of pain
- Generally dysmenorrhea
- sometimes chronic pain
- deep dyspareunea if a low deep endometriosis or a low situated cystic ovarian endometriosis is present.
Localization of pain :
- 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
- dyschesia, i.e. bowel cramps and pain during menstruation, or menstrual blood loss on the stools. Also cyclic diarrhoea 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 can cause ureter pain.
- Subtle Endometriosis is not felt.
- Typical Endometriosis can occasionally be felt as shots
- Cystic ovarian Endometriosis. Only larger cysts can be felt by clinical exam.
- Deep Endometriosis. Clinical exam detects only the very large and low 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 diagnostic accuracy for larger deep endometriosis nodules is high, but limited for smaller lesions
- For a detailed discussion on the diagnostic accuracy of ultrasound read the articles or the experts such as Prof D. Timmerman of Leuven, Dr C. Exacoustos of Rome, and Dr Bazot of Paris. For cystic ovarian endometriosis read the original review article by Van Holsbeke et al. For accuracy read our recent paper
- If you have an endometrioma, this will be diagnosed by US in more than 90%.
- A cystic corpus luteum gives a false positive diagnosis.
- Cancer cannot be excluded. However the risks is very small in women younger than45 years
- Conclusions : Ultrasound imaging has to be interpreted in the clinical context.Therefore ultrasound should be performed by or in close collaboration with the surgeon.
- Malignancy ? The data demonstrate that some 3% of the endometrioma’s are malignant in women after menopause,
Other exams as Cat-scan, Colonoscopy and MRI
These exams are only useful as a preparation for surgery, but limited for diagnosis.
- Cat-scan and colonoscopy can detect very large nodules of deep endometriosis when occluding the bowel. This however is extremely rare.
- MRI is overused for endometriosis and for pain in general.
- For superficial endometriosis MRI is not useful.
- For cystic ovarian endometriosis these exams are not superior to ultrasound.
- For deep endometriosis the larger nodules will be detected, depending on the expertise of the radiologist. MRI however rarely gives information on bowel invasion. Intra-luminal MRI to judge the infiltration of a deep endometriosis in the bowel wall is often used as an alibi to do a bowel resection.
- MRI is useful for diagnosing adenomyosis, as a thickened junctional zone, or as a focal adenomyosis
Decision tree for Diagnosis
- The first decision, is whether a laparoscopy should be planned
- This decision is clear when a deep nodule has been felt, when a cystic ovarian endometriosis was diagnosed at ultrasound, or when a deep nodule was clinically suspected because of severe pain
- The decision is clinical in all other women with pain and/or infertility. Important elements are perineal radiation is almost pathognomonic for deep endometriosis. Radiation to the anterior part of the upper leg suggests ovarian pathology.
- The second decision, after 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 is the gold standard for diagnosis.
- The usefulness of magnetic resonance to predict surgical difficulty is limited.
- Too often it 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 belief that all endometriosis can be diagnosed by anything else than by a laparoscopy
- The biggest problem is that 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 and half treatments
- Medical treatment for long periods of time without a diagnosis in women with pain.
- Gynecologist who believe that subtle lesions cause pain or infertility
- 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.
- Incomplete excision of deep endometriosis by lack of experience and by fear of complications. This results in a second surgery, which moreover is much more difficult.
- Unnecessary rectum resection for recto-vaginal endometriosis