What is the evaluation of endometriosis (endometrial tissue growth outside the uterus)?

From the Guidelines

Evaluation of endometriosis should prioritize a comprehensive approach combining clinical assessment, imaging, and sometimes surgical confirmation, with transvaginal ultrasound as the first-line imaging modality, as supported by the most recent evidence 1.

Initial Evaluation

The initial evaluation should include a detailed history focusing on symptoms like dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. Physical examination may reveal tenderness on palpation, fixed uterine retroversion, or nodularity along the uterosacral ligaments.

Imaging Modalities

• Transvaginal ultrasound is particularly useful for detecting ovarian endometriomas and deep infiltrating endometriosis, with expanded protocol transvaginal ultrasound (TVUS) studies showing higher sensitivity compared to routine pelvic US 1.
• MRI provides better soft tissue contrast and may be used when ultrasound findings are inconclusive or to map extensive disease before surgery, with a sensitivity of 82% to 90% and specificity of 91% to 98% for the diagnosis of endometriomas 1.

Diagnostic Confirmation

The gold standard for diagnosis remains laparoscopy with histological confirmation, which allows direct visualization of lesions and their excision or ablation. During laparoscopy, endometriosis is staged according to the American Society for Reproductive Medicine classification system based on location, depth, and extent of lesions.

Treatment Planning

This systematic evaluation approach ensures accurate diagnosis, which is crucial for developing an appropriate treatment plan tailored to the patient's symptoms, disease severity, and reproductive goals, as treatment of endometriosis is variable and largely determined by the patient’s individualized goals 1.

From the Research

Evaluation of Endometriosis

• Endometriosis is a chronic inflammatory condition defined as endometrial-like tissue proliferating outside the uterus, affecting one in nine Australian women 2.
• The condition can involve bowel, bladder, and all peritoneal structures, and its presentation can vary widely, from infertility in asymptomatic individuals to debilitating pelvic pain, dysmenorrhea, and period-related gastrointestinal or urinary symptoms 3.
• Diagnosis of endometriosis is clinical and often challenging, frequently resulting in delayed diagnosis and treatment, but can be aided by transvaginal ultrasonography, magnetic resonance imaging, and laparoscopy with biopsy 3, 4.

Diagnostic Approaches

• Initial diagnostic investigations for endometriosis include physical examination and pelvic ultrasound, with a thorough gynecological examination, including abdominal and pelvic palpation, speculum examination, and bimanual examination 4, 5.
• Transvaginal ultrasound and pelvic magnetic resonance imaging are recommended to evaluate the extent of the endometriosis and to determine whether any urinary tract or bowel procedures might also be required during surgical resection 4.
• The revised American Society for Reproductive Medicine (rASRM) classification and #ENZIAN classification are essential tools for staging and characterizing the disease 5.

Management Options

• Management of endometriosis requires prompt diagnosis to enable early multidisciplinary intervention that aligns with patient needs and priorities, with options including hormonal and surgical therapies 2.
• Combined hormonal contraceptives with or without nonsteroidal anti-inflammatory drugs are first-line options in managing symptoms, while second-line treatments include gonadotropin-releasing hormone (GnRH) receptor agonists with add-back therapy, GnRH receptor antagonists, and danazol 3.
• Oral GnRH antagonists, including elagolix, relugolix, and linzagolix, allow oral administration, induce dose-dependent reduction of estradiol levels, and do not cause initial flare-up of endometriosis symptoms 6.

Fertility Impact

• Endometriosis is associated with infertility rates ranging from 20% to 68%, with mechanisms including pelvic adhesions, chronic inflammation, and immune dysregulation 5.
• The Endometriosis Fertility Index (EFI) is a valuable predictor of natural conception post-surgery, and the adoption of standardized classification systems such as #ENZIAN and EFI enhances disease staging and fertility prognosis 5.