Diagnosis of Endometriosis
Endometriosis, like other medical conditions, should be diagnosed as early as possible for the best prognosis. Most women visit a gynecologist to investigate one or more of the prominent endometriosis symptoms – pelvic pain worse during menstruation, irregular menses and/or difficulty falling pregnant – without suspecting that endometriosis may be present.
Although endometriosis may be suspected by the clinician during case taking, other tests will be necessary to rule out or confirm the diagnosis. Pelvic pain, especially just before or during menstruation, is the one of the most common symptoms of endometriosis and may be caused by other problems that need to be excluded. Endometriosis may be the cause of infertility in a woman who otherwise has no other symptoms and should be kept in mind as a possible diagnosis while investigating for the cause of infertility.
After taking a thorough history, a physical examination, including a pelvic examination, may be helpful when endometriosis is suspected. It will help exclude other causes but further investigation will be required for a conclusive diagnosis. Nodules may be palpated by the examining finger or pain during examination may be a feature. Other causes of pelvic pain may be identified during a pelvic examination.
This may be helpful in excluding other pelvic pathology, like ovarian cysts (PCOS – polycystic ovarian syndrome) and thus indirectly diagnose endometriosis. Occasionally, endometriosis of the vagina or bladder may be evident during ultrasound.
Surgery – Laparoscopy or Laparotomy
Direct visualization within the abdominal or pelvic cavity during surgery, either by laparotomy (large incision) or more commonly by laparoscopy is the only definitive method of diagnosing endometriosis.
The laparoscope is a long, thin instrument with a light and camera at the end which is inserted into the abdomen through a tiny incision. Laproscopy is the preferred method for direct visualization and the presence of endometrial implants will allow for a conclusive diagnosis of endometriosis. The other benefits of laparoscopy is that it is a day-care procedure that is conducted either under a general or local anesthesia. Usually the endometrial tissue is removed immediately during the laparoscopy to avoid follow-up procedures.
Small bits of endometrial tissues may be removed during a laparotomy or laparoscopic procedure and examined under the microscope to confirm the diagnosis. Even though an area of endometriosis may be missed on a laparoscopic examination, a biopsy of the tissue may be able to conclusively confirm the presence of endometrial cells out of the uterus.
Treatment of Endometriosis
The approach to treatment will depend upon various factors such as severity of symptoms, extent of disease, age, and the desire to fall pregnant. The response to treatment is varied and the endometriosis symptoms may recur after completion of the treatment.
The treatment options for endometriosis include :
- Medication – including pain relievers such as nonsteroidal anti-inflammatory drugs (NSAIDs) and hormones (to control the growth of endometrial tissue).
- Surgery – to remove endometrial tissue from localized areas, or hysterectomy in extreme cases.
Both medication and surgery may be necessary at the same time, especially in cases of infertility where pregnancy is desired. Menopause usually brings about relief from the symptoms of endometriosis.
NSAIDs may help to relieve pain but will not be effective in treating any other symptom of endometriosis.
Hormones help in several ways, namely controlling growth of endometrial tissue, and preventing growth of new adhesions. This also helps to relieve pain. However, hormone therapy may be associated with certain side effects which need to be considered during treatment. Also, the effect may vary from one woman to the other.
The hormones most commonly used for endometriosis are :
- Oral contraceptives (birth control pills containing estrogen and progesterone) may help to relieve pain by regulating the menstrual period.
- Gonadotropin-releasing hormone (GnRH) helps in controlling the menstrual cycle (refer to female hormones). GnRH agonists are drugs with actions similar to but much more potent than natural GnRH. These drugs help to lower the estrogen levels substantially and produce a menopause-like state. Treatment is long-term and may continue beyond 3 months, but normal menstruation may resume within 6 to 10 weeks of stopping treatment. Pain may be reduced effectively, with regression of endometriosis tissue. However, there may be unwanted side effects such as hot flushes, headaches, vaginal dryness, and osteoporosis. GnRH may be given in injection form, as a nasal spray, or as an implant.
- Progestin, such as medroxyprogesterone acetate, works against the action of estrogen on the tissues and can help to reduce the size of the affected area. Menstruation will not occur but there may be some irregular vaginal bleeding. It can be taken orally or by injection. Mood changes, water retention, and weight gain may be some of the unwanted side effects.
- Danazol is a weak male hormone which acts by reducing the estrogen and progesterone levels in a woman’s body, thus stopping menstruation altogether or making it less frequent. Undesirable side effects include weight gain, facial hair growth, oily skin, and fatigue. A woman can fall pregnant while on danazol, which may be harmful for the fetus.
- Aromatase inhibitors, such as anastrozole and letrozole, act by disrupting estrogen formation within the endometrial tissue and by inhibiting estrogen production in other areas of the body. Side effects include loss of bone density and development of multiple follicles during ovulation.
Surgery may be the method of choice in the following conditions :
- Extensive endometriosis
- Severe pain, not relieved by medication
- Severe damage to pelvic structures
Surgery may be done by the following methods :
- Laparoscopy. This is the most common form of surgery done to remove endometrial tissue and the scarring around it. Pain is often relieved by surgery but may recur, especially in severe cases. Laparoscopy may be done both as a diagnostic as well as a treatment procedure.
- Laparotomy. This involves a much larger incision on the abdomen than laparoscopy but offers better visualization and accessibility of tissues.
- Hysterectomy. This is the surgical removal of the uterus and may be done as a last resort where there is severe pain which does not respond to medication. There is less of a chance of recurrence if the ovaries are removed during hysterectomy.