gynecology and obstetrics
Endometriosis
Diagnosis of Endometriosis
Direct visualization, usually during pelvic laparoscopy Sometimes biopsy Diagnosis of endometriosis is suspected based on typical symptoms. Misdiagnosis as pelvic inflammatory disease, urinary tract infection, or irritable bowel syndrome is common. Negative cervical and/or urine cultures suggest the possibility of endometriosis. The diagnosis of endometriosis must be confirmed by direct visualization, usually via pelvic laparoscopy but sometimes via laparotomy, vaginal examination, sigmoidoscopy, or cystoscopy. Biopsy is not required, but results confirm the diagnosis. Macroscopic appearance (eg, clear, red, blue, brown, black) and size of implants vary during the menstrual cycle. However, typically, early lesions are clear or red (hemorrhagic). As the blood in the lesions oxidizes, they turn purple, then brown; they then turn to bluish or purplish brown spots that are>5 mm and resemble powder burns. Microscopically, endometrial glands and stroma are usually present. Stromal elements in the absence of glandular elements indicate a rare variant of endometriosis called stromal endometriosis. Imaging tests do not reliably detect endometriosis; however, these tests sometimes show the extent of endometriosis and thus can be used after diagnosis to monitor the disorder and response to treatment. An ultrasound showing an ovarian cyst consistent with an endometrioma is highly suggestive of the diagnosis. The presence and size of ovarian endometriomas are part of the staging system for endometriosis (stage III: small endometriomas; stage IV: large endometriomas), and a decrease in endometrioma size can show response to treatment. Because endometrial tissue has a unique MR signal, MRI is becoming increasingly useful for evaluating patients who may have endometriosis ( Diagnosis reference ). T1- and T2-weighted MRI can detect some endometriotic lesions in the pelvis, particularly larger lesions. Hemorrhage in the fallopian tubes or in an ovarian cyst without an increase in blood flow suggests endometriosis. Multiple large areas of endometriosis located in the cul de sac indicate severe (stage IV) endometriosis. No laboratory tests contribute to the diagnosis of endometriosis. Consider endometriosis if patients have persistent cyclic pelvic pain, particularly if they also have dyspareunia or infertility. Testing for other Overview of Infertility may be indicated. Staging endometriosis helps physicians formulate a treatment plan and evaluate response to therapy. According to the American Society for Reproductive Medicine, endometriosis may be classified as stage I (minimal), II (mild), III (moderate), or IV (severe), based on Number, location, and depth of implants Presence of endometriomas and filmy or dense adhesions (see table Stages of Endometriosis ) The endometriosis fertility index(EFI) has been developed to stage endometriosis-associated infertility; this system can help predict pregnancy rates after various treatments. Factors used to score the EFI include The woman's age The number of years she has been infertile History or absence of prior pregnancies The least-function score for both fallopian tubes, fimbria, and ovaries The American Society for Reproductive Medicine endometriosis (lesion and total) scores 1.Guerriero S, Saba L, Pascual MA, et al: Transvaginal ultrasound vs magnetic resonance imaging for diagnosing deep infiltrating endometriosis: systematic review and meta‐analysis.Ultrasound Obstet Gynecol51 (5):586–595, 2018. doi: 10.1002/uog.18961 