Endometriosis is often one of the most underdiagnosed, misdiagnosed and mistreated diseases in reproductive aged women. Because the first step to receiving any successful treatment is first a proper diagnosis, it is imperative to find an endometriosis surgeon who will use and review all diagnostic tools to his disposal. This includes imaging techniques such as sonography, MRI, and laparoscopy. However, another crucial diagnostic tool that often goes underappreciated, is a physical exam, which entails the patient providing a thorough discussion of the symptoms they are experiencing and their past medical history. It is important to find a surgeon who will listen to these complaints as such signs as painful periods, painful sex (dyspareunia) and even gastrointestinal distress, which can often be seen in young age women in the form of constipation, painful bowel movements, and diarrhea, can all be highly suggestive indicators for a presumptive endometriosis diagnosis. Thus it is key to find a surgeon who is not only knowledgeable, but also compassionate and patient enough to listen to your full story, as all these elements can help to make up a highly accurate, but still speculative, diagnosis.
Diagnosing endometriosis requires 3 levels of diagnostic evaluation:
Step 1 (pre-surgery): The initial stage is a clinical examination and appropriate testing, this includes a pelvic examination and ultrasound. During this time, patients thoroughly recount their current complaints and symptoms, as their doctor intently listens in order to build trust that will facilitate long time care. Upon physical examination, such findings as cervix, pelvic side and posterior thigh tenderness, which can radiate as far back to the cervix at the rectal wall, can all be key telling signs of endometriosis lesions and their possible location. Sonogram technology can help confirm the cause of this tenderness. Finally, a rectal exam may also be conducted if there is diffuse pelvic tenderness as the will want to determine if there is localized rectovaginal tenderness, a key sign of rectovaginal disease and possible nodules.
Step 2 (during surgery): The second stage is visual diagnosis by recognition of endometriotic lesions through laparoscopy. This will be performed in the operating room, during laparoscopic surgery.
Step 3 (after surgery): The final formal diagnosis of endometriosis cannot be made without pathologic examination under a microscope, thus surgical specimens obtained through laparoscopic deep excision surgery must be sent off to the lab. It usually takes a few days after surgery to assess.
What are forms of testing performed pre-surgery?
Pelvic Exam: This physical examination of a patient’s pelvis and pelvic organs, is a part of any fully comprehensive gynecological exam. During this exam, a physician will look for any and all points of pelvic tenderness. Through a pelvic exam, your doctor will be able to gain a better understanding of your symptoms and any pain you may be experiencing. If your physician specializes in endometriosis, they may even be able to diagnose such conditions as frozen pelvis.
Transvaginal Ultrasound: Ultrasound is a safe and painless technique that uses sound waves to create detailed images of inside the body. A small probe, called a transducer, is inserted into your vagina, much like a tampon. Sound waves will then pass harmlessly through the skin from the transducer, bouncing off certain organs and tissue in the body creating "echoes". The echoes are reflected back to the transducer, which converts the echoes to electrical signals in order to produce an image. The images are viewed in real-time on a monitor and are also recorded and photographed for your physician to review. It is important to note, that this test can be performed during menstruation.
Sonohysterography: During this imaging technique, fluid is injected through the cervix into the uterus. Ultrasound is then used to make images of the uterine cavity, which shows more detail of the inside of the uterus than if an ultrasound was performed alone. This procedure is done to find the underlying causes of abnormal uterine bleeding, miscarriage, and infertility, as it can detect:
Abnormal uterine growths (i.e. fibroids or polyps)
Abnormal uterine shape
This procedure is not scheduled during your menstrual cycle or during a period when you are having abnormal bleeding. In cases of abnormal bleeding, the test will be done as soon as the bleeding stops. After this exam, you may have some cramping, spotting and watery discharge. The procedure is generally safe, but in rare cases, there is a risk of pelvic infection.
MRI: Magnetic resonance imaging (MRI) is a noninvasive imaging device that produces strong magnetic field and radio waves that are used to create detailed images of the bodies tissue, organs, and other areas. An MRI differs from a CT scan as it uses low-frequency magnetic fields as opposed to the high energy X-rays that a CT scan uses, which often put patients at a risk for radiation exposure. An MRI produces much more comprehensive and detailed imaging than an ultrasound, as it often encompasses the entire body. This begs the question, why receive an ultrasound and not an MRI? First and foremost, MRI is much more expensive than obtaining an ultrasound. MRI testing is also not conducted in the office of your everyday primary care physician or gynecologist, but rather it is done upon referral. Nevertheless, MRI testing can be a very useful tool for you doctor in obtaining an idea of the extensiveness to which your endometriosis has spread. Thus it is very common for your specialist to ask for an MRI test to be conducted, prior to surgical treatment for endometriosis.
What are forms of testing performed during surgery?
Hysteroscopy: An imaging technique performed in the operating room in order to view the lining of the uterus (endometrium). This is done using a thin tool with a light and camera (the hysteroscope) attached to its tip, which is gently inserted into the vagina, through the cervix, and into the uterus. Using this technique, a surgeon will be able to see if there is any uterine cause for heavy menstrual bleeding, pelvic pain or infertility. This is very useful in cases of adenomyosis.
Laparoscopy: Laparoscopy entails visualization of the abdomen and pelvic cavity through an instrument known as the laparoscope. Performed under general anesthesia, the laparoscope is inserted through small incisions made in the abdominal and pelvic cavity, which are sutured back together after surgery. The goal of this technique is to make small incisions at a distance from the operating location in order to ensure minimal invasion. This method allows your surgeon to inspect the abdominal and pelvic regions (and beyond, as needed) to diagnose and subsequently remove endometrial lesions, utilizing his or her surgical modality and tool of choice (for example, the laser or excision clippers).
Why is endometriosis difficult to diagnose?
Endometriosis exists in different forms with different symptoms, signs, and prognoses. Though a growth in awareness of the variations of the disease has given rise to an increase in diagnoses, it still remains a seldom recognized and poorly understood illness. Confusion about appropriate management continues to surround the disease.
How is endometriosis formally diagnosed?
Despite advances in diagnostic technology and all the other presurgical imaging tests that help determine whether or not a patient may have endometriosis, a confirmation of endometriosis requires surgical biopsy. This is commonly obtained through minimally invasive laparoscopy.
Are there other ways to formally diagnose endometriosis?
The use of ultrasounds, magnetic resonance imaging (MRI), computerized tomography (CT scan), and certain endometrial biopsy samples may be used as part of a diagnostic workup, but to date, anything less than surgical confirmation of endometriosis is considered uncertain. There are also no specific and sensitive blood tests to diagnose endometriosis.
What is our approach to diagnosing endometriosis pre-surgery?
Physical Exam: There are a variety of tests that we like to perform in diagnosing endometriosis before a patient has surgery. After your symptoms, history, and complaints are well noted during an examination, we will conduct a thorough physical exam, which on top of a comprehensive pelvic exam, will include other tests such as checking for neuropathy in your lower back and legs, checking for costovertebral angle (CVA) tenderness, inspecting the cervix and evaluating the upper vagina with digital palpation. Nodularity, thickening, and shortening of the uterosacral ligament, rectovaginal, cul-de-sac, and lateral vaginal walls are all evaluated in this manner. Tenderness of these locations is significant in measuring the extent of the disease. Lastly, a gentle single digital pelvic bimanual examination is performed. The tenderness of the cervix to touching and mobilization during this exam (CMT, or cervical motion tenderness) is promptly noted, and subsequently the anterior and posterior cervix, then the upper vagina is also evaluated with digital palpation.
Transvaginal Ultrasound: For patients experiencing painful bowel movements, we like to perform a transvaginal rectovaginal sonogram (transvaginal ultrasonography or transvaginal ultrasound) as well. Transvaginal Ultrasound performed after a bowel preparation improves the ability to properly diagnose intestinal lesions and provides invaluable details, including which layers of the intestine, are affected and the distance between the lesion(s) and the anal border. The uterine walls, endometrial canal, and endometrial cavity are then carefully evaluated for the presence of adenomyosis, fibroids, and polyps. The cul-de-sac and rectovaginal septum are then scanned. Finally, it is important during a transvaginal ultrasound to inspect the ovaries. Having treated women with endometriosis for nearly three decades, we have come to strongly believe that ovarian cancer is directly associated with endometriosis. Transvaginal ultrasound has consistently proven to be the most promising imaging method for routine screening of ovarian cancer. It is also very effective in screening for endometriosis.
Sonohysterography: Sonohysterography is used along with an ultrasound to make detailed images of the uterine cavity in order to aid in identifying endometrial lesions of submucosal fibroids and polyps, particularly in patients with a history of infertility and heavy periods, regardless of their pain.
What is our approach to diagnosing endometriosis during surgery?
Hysteroscopy: Before any excision surgery, we will conduct a hysteroscopy in order to visualize the lining of the uterus (endometrium), allowing us to see if there is any uterine cause for heavy menstrual bleeding, pelvic pain or infertility.
Laparoscopy: Following your hysteroscopy, small incisions will be made into the abdominal and pelvic region. A laparoscope is then inserted into the incision sites and the images are depicted on two monitors, one for the surgeon and one for the attending resident. All surgeries we conduct are done via laparoscopy. This allows us to clearly visualize any believed endometriosis lesions.
ABC technique (™),: One diagnostic tool that we use, which is strictly unique to us, is the Aqua Blue Contrast Technique (ABC). This patented surgical technique is used during laparoscopic excision surgery in order to clearly visualize endometriosis scar tissue by use of an aqua blue contrast solution. While some lesions may be invisible to the typical surgeon using a laparoscopic light, the ABC technique eliminates light reflection in order for the surgeon to visualize, and thus identify and excise endometriosis lesions fully. Using this method, we ensure our patients that we can identify areas of endometriosis development throughout the body.
So many patients diagnosed with endometriosis go through several surgeries, only to have their symptoms keep returning. Often times the reason for this lies in the fact that not all of their endometriosis lesions have been identified and thus much more scar tissue remains in the body. Therefore it is crucial to research and read how your surgeon will identify endometriosis lesions throughout the body, in order to ensure a thorough and successful surgery.
Using common diagnostic tools such as ultrasound, MRI, and hysteroscopy, in combination with our unique method of laparoscopy with ABC technique, we spare no expense in ensuring that no visible endometriosis lesion goes undetected. But on top of all of these diagnostic tools, the first step in identifying your endometriosis is through communication.