Endometroisis
Diagnosis
Endometriosis: primarily a clinically diagnosis
Endometriosis can be diagnosed from puberty to menopause. There is often a delay in diagnosis (7 to 10 years between the first symptoms and diagnosis).
Patients who have their periods monthly and patients who do not take hormonal contraception often present with moreendometriosis symptoms. So endometriosis is often diagnosed in adolescents, in younger women who stop taking contraception to become pregnant or in multiparous patients who switch to a non-hormonal contraceptive method (copper IUD, tubal sterilization, etc.)
For some patients experiencing few or no symptoms, diagnosis of endometriosis may be fortuitous following tests or surgery for other conditions.
Clinical examination
The diagnosis of endometriosis is mostly based on clinical examination. An experienced clinician can generally diagnose endometriosis before complementary examinations are carried out, based on a patient’s medical history and specific,detailed physical examination.
Additional examinations allow assessment of the severity of the disease and focused treatment. They must be carried out by radiologists with experience in endometriosis. Results that appear normal may also confirm the diagnosis, particularly in cases of superficial endometriosis.
Taking a patient’s medical history
A Patient’s medical history is fundamental and often sufficient to suggest a diagnosis of endometriosis. The objective is to link the chronology of painful symptoms to the onset of menstruation. The other symptoms previously mentioned should also be investigated (pelvic pain, dyspareunia, digestive and urinary symptoms, etc.).
Abdominal examination
This examination may provoke a general discomfort (sensitive around the pelvis or colon) but little other information. However, during a period of acute pain, the results may resemble digestive conditions that require surgery. On rare occasions certain complications may indeed require digestive surgery (occlusion, renal colic).
Vaginal examination with a speculum
This test must be carried out with great care, as contact with vaginal pouches is generally painful. It is often normal, but may reveal a nodule of deep endometriosis infiltrating the vagina, in the form of a fibrous retraction, a developing lesion (see picture) or black microcysts.
Vaginal examination
Vaginal examination is essential for diagnosis of deep endometriosis, but cannot be performed for patients who have not had sexual intercourse. Several elements can be investigated during the examination:
- A soft but tender posterior vaginal pouch may be the sign of superficial endometriosis of the pouch of Douglas.
- A fibrous nodule or a lesion of the vaginal pouch, often sensitive, may indicate deep endometriosis.
- An enlarged and tender uterus may indicate adenomyosis.
- A cystic mass may indicate ovarian endometrioma.
Rectal examination
It is useful especially in case of suspicion of deep retro-cervical endometriosis nodules, and makes it possible to assess the presence of infiltration of the rectum or parametria.
Complementary examinations
Endovaginal pelvic ultrasound
Considered as a first line imaging examination, ultrasound is efficient when carried out by an experienced radiologist or gynecologist. It allows the identification of:
- Ovarian endometrioma (ovarian cysts with finely granulated contents, which persist over several cycles unlike hemorrhagic cysts)
- Adenomyosis
- Deep endometriosis nodules of the uterosacral ligaments, the bladder, the rectum and distal sigmoid colon
- Cystic collections within the pelvis such as obstructed and dilated fallopian tubes due to accumulation of menstrual blood (hematosalpinx), peritoneal pseudocysts due to adhesions, etc.
Abdominal ultrasound enables diagnosis of endometriosis complications, such as ureteral stenosis with pyelocaliceal dilation, kidney atrophy, extensive intra-abdominal endometriosis with accumulation of ascites, etc.)
Magnetic resonance imaging (MRI)
Abdomino-pelvic magnetic resonance imaging (MRI) is a very efficient examination which allows not only the diagnosis but also the precise mapping of intra-pelvic and intra-abdominal endometriosis lesions. We almost always ask our patients to undergo an MRI before surgery. This enables us to identify:
- Ovarian endometriomas, that contain blood and have a very characteristic appearance (hypersignal T1 sequence with fat saturation and hyposignal T2 sequence (photo 1);
- Deep endometriosis nodules are star-shaped (T1 and T2 hyposignal), retractile, infiltrate neighbouring organs (rectum, sigmoid colon, vagina, bladder, etc) and sometimes contain endometriosis microcysts (photo 2) ;
- Adenomyosis is confirmed by enlarging of the junctional zone or by the presence of multiple hypersignal microspots in the myometrium (photo 3) ;
- Complications of endometriosis (hematosalpinx, ureteral stenosis with pyelocaliceal dilation or hydronephrosis, infiltration of the parametrium or sacral roots, stenosis of the digestive tract, etc.)
Other examinations may be prescribed in cases of severe endometriosis, depending on where endometrosis lesions are found by echography or MRI. They will be prescribed for some patients only.
These include endorectal ultrasound and colonography in the case of colorectal endometriosis, cystoscopy, urogram or uro-MRI in the case of endometriosis of the urinary tract, MRI and/or scan of the diaphragm in the case of endometriosis of the diaphragm.
No specific biological tests are used. An increase in CA125 level may be observed in the case of diffuse ovarian or peritoneal endometriosis, but is not part of the preoperative examinations.
Research is underway to identify a blood marker that could indicate the presence of endometriosis by a simple blood test.
Laparoscopy
Laparoscopy allows confirmation of the diagnosis though exploration of the abdominal cavity with targeted biopsies and anatomopathological analysis.
In case of infertility, it allows prognostic classification according to the AFSr (American Fertility Society revised), and sometimes treatment of superficial lesions.
Laparoscopy is not essential before initiating medical treatment in patients in whom endometriosis is strongly suspected after clinical examination and scans. Laparoscopy is reserved for patients where there is a doubt over the diagnosis of endometriosis. It is not recommended to use laparoscopy to confirm clear scan results.
Currently, laparoscopy is mainly used for treatment of endometriotic lesions.
The diagnosis of endometriosis is often made when contraception is stopped.
When the contraceptive pill is stopped
Between the ages of 20 and 30, when women stop taking the contraceptive pill to try to get pregnant, the absence of medication leads to very painful menstrual periods. X-ray examinations may reveal previously unrecognized endometriosis lesions.
After childbirth
or at any other time in life, when patients opt for a mechanical contraceptive method (copper IUD, tubal ligation or obturation); the resumption of periods without any medical inhibition reveals previously unrecognized endometriosis lesions, which become symptomatic.
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