How is endometriosis diagnosed?

I think laparoscopy, as I said, the surgical approach key hole surgery is the gold standard for the diagnosis of endometriosis and in the presence of ovarian cysts that can be seen on ultrasound scan, then of course that is a non-surgical way to assess the ovaries and the pelvis and determine the presence of the cysts in the ovaries. The superficial endometriosis, that normally lies on the surface of the pelvis, cannot be diagnosed by ultrasound scan. There are however some advanced stages of endometriosis, especially stage IV, where there is an involvement of the rectum and the space between the uterus and the vagina, well by an MRI scan can be quite conclusive and confirm the diagnosis of deep infiltrating endometriosis.

We can diagnose endometriosis on the basis of symptoms which are progressively painful periods, painful intercourse and that could be enough to start treatment and see symptomatic relief. The other diagnostic modalities could be doing the imaging which is a pelvic ultrasound scan and sometimes you have to do an MRI scan which is more informative and gives you more detail about the disease. Sometimes you can do some blood marker which is CA 125 level which is raised in endometriosis usually. Although, it can be raised in other problems as well but that helps in the diagnosis and then we can do the surgery which is diagnostic laparoscopy and we can treat the endometriosis at the same time so, that is putting the camera and telescope through the belly button, under the anaesthetic and we can see and we can treat the disease at the same time.

I will be very systematic in diagnosis. The first step to diagnose women with endometriosis is to be aware actually yourself about endometriosis, to be very literate about endometriosis, you read a lot, you are up to date with the literature because from history, you can diagnose endometriosis from history itself. So listen carefully to what woman is complaining about, her pattern of pain, how it happened, did she took any medications that exasperate, any diet that exasperate this pain, when she stopped her contraceptive spells is this pain increased or decreased ,when she resumed these pills increase or decrease, what kind of nature of this pain in relation to her period, in relation to her intercourse, details of this pain.
I think, first things first, history is very important and to be very precise and know exactly what you are asking about. The second thing, sometimes your doctor may ask to perform an internal exam and in this internal exam will try to check the neck of the womb, the area around the womb itself or sometimes they may find some endometriosis islands inside the vagina itself. Sometimes they may feel the nodules in the back of the vagina between the rectum and the vagina so, it could be just raise our suspicions if we talk proper history and then we did exam and we find something inside the examination so, this can raise our concern that you have endometriosis. Sometimes, even before doing any scans, you can’t feel any mass inside the pelvis – it could be a deep endometriosis and you have a chocolate cyst or endometriosis in the ovary and endometriosis on the other ovary and the both are very close. We are calling it kissing ovaries. These ovaries just enlarged and kissed each other and you can feel it from the pelvis. You will find that all the womb, the ovaries are not moving while you exam – this is called the frozen pelvis from too much scars, adhesion- everything. In turn, you can suspect this is endometriosis.
So, if it speaks like Minnie Mouse, if it acts like Minnie Mouse or if it behaves like Minnie Mouse, it’s a Minnie Mouse. This is not a magic science to diagnose endometriosis and now because a long time ago what we learned in medicine the gold standard for diagnosis of endometriosis is laparoscopy and keyhole surgery, we simply go by a pencil or a pen a camera like a pen in your belly bottom and see inside your pelvis what’s going on there and we can see the islands this is endometriosis. Believe me, this is something very strange, sometimes you can’t see endometriosis because it’s also different shapes inside the lining of the womb. You may find black nodules, you may find brown nodules, you may find recent scars in you, may find active dots of endometriosis or active glands of endometriosis – just very hyperemic or very red and you may find some windows inside the peritoneum itself – it’s called the hallmark sign, some windows and gapping and cupping inside the peritoneum which is the lining of your tummy all the lining of your tummy all the area around your pelvis. So it’s very strange and the recommendation when you are doing laparoscopy is to take a biopsy from this glass and do a histopathology exam then, we can say it’s endometriosis and if you can imagine how many years a woman with endometriosis has.
If you can imagine how many years a woman with endometriosis went to the doctor, prescribed painkillers, then prescribed hormonal medication and then okay “pain is not relieving, hormones are not helping and the side effects from hormones so, what else can I do? Please doctor” – “so okay it may be endometriosis, we will go by a laparoscopy’ and if accidentally we couldn’t find or suspect all these signs of endometriosis – I describe all the picture of endoscopic endometriosis, it could be misdiagnosed and again the woman, the poor lady, she doesn’t know what’s causing this pain. So, this is the problem about the diagnosis. Laparoscopic can be a diagnosis, if it’s for a longer time and actually it was the golden standard and now the debate between ultrasonography or MRI scan. In ultrasonography, we can find that if it’s something in the pelvis we can see endometriosis on the ovary which in the form of endometriotic, endometriosis. Endometrioma it is found by like 40% in women with endometriosis so, it’s very common and we will discuss its effect on infertility later on but you can find these nodules between the vagina and the rectum and sometimes this is very disfiguring nodule and very very uncomfortable to have something inside the rectum which makes you feeling very very difficult sensation in passing, opening your bowel or anything. It may need to have a surgery and this may help you to just discuss with the surgeon how the surgery will be done for this kind of pain so, this can be diagnosed by ultrasound if you are aware and you have proper training and you know what you are looking for. If you have urinary symptoms, we can see bladder endometriosis, bladder nodules on the scan, on the 2D scan, not 3D scan. On the 2D scan, you can expect you to recycle nodule endometriosis by 2D scan so this is very helpful to be aware about what’s inside. Just listen, try to correlate everything with what you are seeing. MRI scans are also helpful. We well recommend MRI scan because the debate MRI is a gold standard and ultrasound is a golden standard – this is after it was diagnosed with laparoscopy or surgery – is the gold standard for diagnosis. Now the debate between ultrasound and MRI but I will recommend MRI scan for any symptoms away from the pelvis so, it can help to diagnosis endometriosis on the diaphragm, on the bowel itself, up around the stomach, in any place in your in your tummy or on the lung so, it can help actually to see this endometriotic soft tissue gland – it’s very helpful to have MRI scan too. Especially if you are going to have a major surgery for endometriosis which another story will speak about later. So, simply the diagnosis itself could be done very easily, by taking proper history and starting to work on it very early rather than waiting for a long journey to be diagnosed by your specialist.

Yes, so a normal ultrasound, transvaginal ultrasound will tell us about endometriosis but it can miss the subclinical or grade I stages where the ovarian cyst has not yet formed but a very trained ultrasonographer will catch that the uterus is less mobile, it might be because of the adhesions the uterus is not not very mobile, many of the times the uterus is retroverted very immobile and the patient is feeling pain during the passage of the probe I mean, a little more than the general population. So, these are the things which increases the index of suspicion from a doctor’s perspective that this patient might have endometriosis and the typical history of triple D (Dysmenorrhea, Dyspareunia, Deep chronic pelvic pain)will also point to examination and the uterosacral ligaments which are deep down connecting the vagina back to the sacrum, they generally have the deposits of endometriosis and the patients feel pain at the time of the vaginal examination because of that. So, these are the indicators, they are all indirect indicators. The direct indicator is just the laparoscopy but I think we should always keep a high threshold for any surgery because every surgery can have complications so, the reason that we are doing the surgery should be substantive enough for us to actually do a surgery because there’s anesthesia involved, at the end of the day it’s a surgery and there is a possibility of a complication. So every surgery should only be done when enough indication is there to do the surgery but before the surgery, we generally have the general pelvic examination or the ultrasound. Another thing which generally people do is MRI but it is not going to add if a very trained doctor is doing an ultrasonography it is going to give enough information that MRI would not add much to that information.

At the moment, we don’t have a simple blood test or urine test that can diagnose endometriosis. An ultrasound scan is sometimes helpful if the endometriosis is on the ovaries and it’s forming a cyst – for obvious reasons that will show up but we talk about the gold standard for endometriosis being surgery and that’s because a lot of endometriosis isn’t seen on scans, on imaging and so you need to have a laparoscopy keyhole surgery to actually identify the disease properly.