From the Guidelines
Endometriosis is definitively diagnosed through a combination of clinical evaluation, imaging studies, and laparoscopic surgery with biopsy confirmation, with the most recent evidence supporting the use of transvaginal ultrasound or MRI as the initial imaging modality 1.
Diagnostic Approach
The diagnosis of endometriosis is challenging due to variable presenting symptoms and nonspecific physical examination findings. A thorough clinical evaluation, including a detailed medical history and pelvic examination, is essential to suspect endometriosis.
Imaging Studies
Imaging studies such as transvaginal ultrasound or MRI can help identify endometriomas (chocolate cysts) or deep infiltrating endometriosis. The American College of Radiology recommends using an MRI protocol tailored for detection of deep endometriosis, with moderate bladder distention and vaginal contrast to improve lesion conspicuity 1.
Laparoscopic Surgery
Laparoscopic surgery with biopsy confirmation is the definitive diagnostic method for endometriosis. This minimally invasive procedure allows a surgeon to examine the pelvic cavity for endometrial-like tissue outside the uterus and take samples for pathological examination.
Recommendations
The most recent evidence supports the following recommendations:
- Transvaginal ultrasound or MRI pelvis without and with IV contrast is usually appropriate as the initial imaging of clinically suspected pelvic endometriosis in an adult patient 1.
- MRI pelvis without and with IV contrast or MRI pelvis without IV contrast is usually appropriate as the next imaging study for characterization or treatment planning after an indeterminate or negative US in an adult patient with clinically suspected pelvis endometriosis 1. In summary, a combination of clinical evaluation, imaging studies, and laparoscopic surgery with biopsy confirmation is the most effective approach to diagnose endometriosis, with transvaginal ultrasound or MRI being the recommended initial imaging modalities 1.
From the Research
Diagnosis of Endometriosis
To diagnose endometriosis, the following steps can be taken:
- A thorough history and pelvic examination are essential in assessing symptoms and signs of endometriosis 2
- Transvaginal ultrasound and/or magnetic resonance imaging can be used to aid in diagnosis 2, 3
- If endometriosis is suspected based on clinical symptoms but imaging is negative or empirical treatment is ineffective, referral to a gynaecologist for further assessment and consideration of laparoscopy is recommended 2
- Laparoscopy is considered the gold standard for diagnosing endometriosis, but it is an invasive surgical procedure 4
Clinical Findings and Symptoms
Endometriosis can present with diverse symptomatology, including:
- Pelvic pain 4, 2, 5
- Infertility 4, 2, 5
- Decreased quality of life 4
- Interference with daily life, relationships, and livelihood 4
- Symptoms of endometriosis can be chronic, systemic, inflammatory, and heterogeneous in nature 4
Diagnostic Challenges
Diagnosing endometriosis can be challenging due to:
- The invasive nature of the gold standard diagnostic procedure (laparoscopy) 4
- Diverse symptomatology, which can lead to misdiagnoses and delays in diagnosis 4
- The need for increased patient education and timely referral to a women's healthcare provider 4
- The importance of shifting the physician approach to the disorder, focusing on symptoms, signs, and clinical findings rather than solely on surgical findings and pelvic lesions 4