Endometriosis is a disease of the female reproductive system, and it occurs when the endometrium — tissue that lines inside the uterus — starts to grow outside the uterus. The reasons for the development of endometriosis are not fully understood, but researchers believe it could be linked to many causes: genetics; abnormalities in the levels of the hormones estrogen and progesterone, which influences the menstrual cycle; a dysfunction in the immune system that disables the destruction of endometrial tissue; or environmental exposure in the womb to chemicals like dioxin.
Diagnosing endometriosis can be difficult, but it starts with knowing the symptoms. The two main consequences of the disease are pain and infertility, while other signs include painful, even debilitating menstrual cramps, which may get worse over time; pain during or after sex; pain in the intestine or lower abdomen; painful bowel movements or painful urination during menstrual periods, heavy menstrual periods; premenstrual spotting or bleeding between periods; painful bladder syndrome; digestive or gastrointestinal symptoms similar to a bowel disorder; as well as fatigue, tiredness, or lack of energy.
Noninvasive diagnostic methods
When a patient presents symptoms of endometriosis, a physician usually starts by investigating medical and family history, as well as by conducting a complete physical exam, including speculum and bimanual examination. During a pelvic exam, the physician palpates the pelvis to search for abnormalities, like cysts or scars.
If the signs indicate the presence of the disease, the next step is an imaging examination, and the healthcare provider may request an ultrasound, MRI and CT scans, which are exams used to visualize the abdomen and reproductive organs without the need for invasive procedures, but that have limited results.
The study “Invasive and non-invasive methods for the diagnosis of endometriosis” revealed that “imaging has limited utility in the diagnosis of endometriosis, as it lacks adequate resolution to identify adhesions or superficial peritoneal implants. Ultrasound is cheap and easy to perform, but user-dependent; MRI is more accurate but considerably more expensive. As CT of the pelvis does not visualize pelvic organs well, it is not useful in the diagnosis of endometriosis. An important role for the CT scan with contrast is to detect ureteral involvement and possible renal insufficiency.”
Invasive diagnostic procedures
Despite the common use of noninvasive methods of diagnosis on patients suspected to have endometriosis, the authors of the same study note that surgery is the only fully viable method to detect the disease.
“The gold standard for the diagnosis of endometriosis has been visual inspection by laparoscopy, preferably with histological confirmation. Because there is no good noninvasive test for endometriosis, there is often a significant delay in diagnosis of this disease. Imaging that confirms an endometriotic cyst or deep infiltrating endometriosis may help guide surgical therapeutic approaches. No serum marker has been found to diagnose endometriosis with adequate sensitivity and specificity.”
Laparoscopy is the name of the surgery used to confirm the diagnosis of endometriosis. The procedure consists of the observation of the interior of the abdomen. The patient is asleep under general anesthesia, while the surgeon makes small incisions near the navel to insert the surgical instruments and a small camera. Then the surgeon will search for endometrial tissue outside the uterus, which can provide information about the location, extent, and size of the endometrial implants. During the laparoscopy, the surgeon may also remove a sample of tissue to conduct a biopsy.
Not easy to diagnose endometriosis
The symptoms of endometriosis may be confused with those of other diseases, while some physicians may want to avoid surgery to confirm the diagnosis. In addition, the symptoms are not constant and vary due to many factors. These reasons explain why endometriosis is still a disease that is difficult to diagnose, with high rates of misdiagnosis or delayed diagnosis.
A survey conducted by the National Endometriosis Society revealed that 32 percent of patients who suffer from the disease saw one other specialist before being referred to a gynecologist, and 25 percent consulted two other specialists before seeing another specialist.
“Before diagnosis, over half the patients had been told that there was nothing wrong with them,” Dr. Andrew Prentice wrote in an article he authored called “Endometriosis,” published in The BMJ. “The consequence of this leads to a delay in the start of effective treatment and a sense of disillusionment in the patient.”
“Painful symptoms in women of childbearing age may be caused by endometriosis, particularly when the symptoms have a cyclical element,” he wrote. “All doctors, therefore, should be alert to this possibility even when the patient presents with apparently non-gynecological symptoms.”
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