Diagnosis and Treatment
The endometriosis diagnosis is established after performing a series of tests, including a physical consultation. In some cases, the disease can be asymptomatic and the only clue is infertility.
Clinical examination and anamnesis (discussion with the patient) often lead towards the correct endometriosis diagnosis. Ultrasound examination and the MRI exam (with special protocol) can give important information about the degree of infiltration of the neighboring organs. The most common infiltrated extra-genital organs are rectum, sigmoid colon, bladder, pelvic ureters, and the small intestine.
Other investigations that can give preoperative information are CT scan, urography and cystoscopy examination. They are very helpful in deciding the type of intervention so that the patient can be informed about possible surgical interventions (intestinal resections, bladder resection, etc.). Also, depending on the type of intervention, the patient can be adequately informed about possible postoperative complications.
The CA-125 marker, so commonly associated with the disease in the past, has a limited role. It can be increased when there are endometriotic cysts, but it often has normal values in deep lesions – endometriotic nodules.
MYTH: “Pregnancy /menopause cures endometriosis“
This is a false premise that stems from Sampson’s retrograde theory in which the endometriotic lesions act like the lining of the uterus and respond to estrogen deprivation. It has been proven that endometriosis cells make their own estrogen.
Methods of Establishing
ENDOMETRIOSIS DIAGNOSIS
The diagnosis of suspicion of endometriosis is based on cyclical pain; sometimes, patients do not have intense pain, but the clinical/ultrasound examination reveals the presence of deep lesions or ovarian endometriomas. In general, patients present to a doctor for two reasons: unbearable pelvic pain and infertility.
When a patient complains of chronic pelvic pain, cyclic (severe dysmenorrhea) the suspicion for endometriosis should be raised. However, there are severe pelvic endometriosis patients with minimal pain, the main problem being intestinal transit disorders (constipation/diarrhea), and sometimes the main symptoms are urinary disorders. What is important to remember is that regardless of the location of the pain, the menstrual character should play an important role in the diagnosis.
The European Society of Human Reproduction Embryology clinical practice guidelines of women with endometriosis published in 2013, states that endometriosis diagnosis is corroborated with the patient history, symptoms and signs, physical examination, imaging techniques, and finally proven by histology after laparoscopy.
Patient history, pelvic exam and imaging are methods of a presumptive diagnosis. Other European guidelines regarding the management and diagnosis of endometriosis recommend that the possibility of endometriosis should not be excluded if the imaging tests are normal.
Anamnesis
The evaluation of the patient should start with a medical history discussion. This is an essential primary step in establishing the cause of the symptoms. By obtaining patient history about symptoms, and previous medical investigations, a presumptive diagnosis can be made. Based on the information collected, further investigations can be recommended if the diagnosis is not clear enough or to help with the treatment method.
Physical examination
When doing a pelvic exam, the doctor feels for any abnormalities and mobility of the pelvic organs. The bimanual exam consists of two fingers inserted into the vagina to evaluate the cervix, uterus and adnexa while
pressing on the lower abdomen with the other hand. The exam can evidentiate pelvic masses, rectovaginal and uterosacral nodules, tenderness of the uterus, adhesions or frozen pelvis, and adnexal masses.
Imaging
Noninvasive methods of diagnosis such as MRI, abdominal and transvaginal scans can be useful in the diagnosis of retroperitoneal endometriosis and deep infiltrating lesions, however, they have limited utility in diagnosing adhesions, peritoneal and superficial lesions, due to the limited resolution.
Abdominal ultrasound can diagnose ovarian cysts while the transvaginal scan can help diagnose endometriomas and deep nodules. MRI is useful for assessing the extension of the disease, for planning a more appropriate surgical approach, and being prepared regarding all the necessary specialists. Superficial lesions less than 5mm are often not visible on MRI either, as they are tiny or flat (no mass).
MRI can visualize endometriosis lesions on the bladder, and it can also determine how much the lesion/nodule is infiltrating the wall of the intestines, the distance from the anus and the length of the affected area.
This theory has not been disproven by research and it does not match the fact that endometriosis was found in young girls, men, fetuses, and animals. Based on the history of endometriosis, when Sampson published his first data, the term endometriosis did not exist. In 1921, Sampson published a study done on 23 women, and only 9 cases were histologically proved endometrial type ovarian cysts.
Laparoscopy
History and physical findings raise a strong suspicion of endometriosis; however, the correct diagnosis requires surgery with histological verification of endometrial glands and/or stroma. Considered the gold standard in the proper diagnosis for endometriosis, laparoscopy is the most used method at the moment.
The ESHRE guide for clinicians and patients for the management of endometriosis, states that laparoscopy is the final and correct diagnosis. In the guide it is noted that diagnosis during laparoscopy is dependent on the ability of the surgeon to recognize the disease in all its different appearances.
The following organizations consider laparoscopy as the correct diagnosis method for endometriosis: American College of Obstetrician and Gynecologists, (UK) National Institute for Health and Care Excellence, Royal College of Obstetricians and Gynecologists, National German Guidelines France, CNGOF/HAS.
Hormonal Treatment for Endometriosis
There are many types of drugs used as endometriosis treatment: anti-inflammatory medications, anti-allergic medications and many hormonal drugs. All of these therapeutic options only combat the symptoms of the disease – pelvic pain.
Hormonal therapies do not treat endometriosis, they only suppress the symptoms, and once the therapy is stopped, symptoms will return. Medications include gonadotropin-releasing hormone (GnRH) agonists, progestins, oral contraceptive pills, and androgens. All these treatments have similar clinical efficacy in terms of reduction in pain-related symptoms and duration of relief. As of now, no studies have shown that hormones cure the disease. There is enough evidence showing that symptoms return once the medication is stopped.
A study done at the Royal Free Hospital in London showed that patients with endometriosis treated with GnRH are highly likely to suffer a recurrence of their disease, particularly if their condition is severe at the outset. Fifth-year recurrence rates were 36.9% for minimal disease and 74.4% for severe disease.
Hormonal treatments, like almost any known drug, generally have severe side effects that are difficult to tolerate by many patients. Gn-RH analogues (Diphereline, Zoladex, Lupron, Orilissa) induce menopause, with all its adverse effects.
GnRH side effects
Some side effects of GnRH are usual menopause symptoms such as hot flushes, mood changes, anxiety, vaginal dryness, headaches, dizziness, nervousness, irritability and sleeplessness, depression and other mood disorders. Other side effects are more severe such as pain & fibromyalgia, musculoskeletal & articular disorders, memory and psychotic disorders, autoimmune thyroiditis, blood sugar rise, difficulty breathing, chest pain, liver function abnormality, vision abnormality and others.
Surgical Therapy
Surgery for deep endometriosis is a complex surgery involving exposure of the pelvic and abdominal organs. Surgery remains the only method of establishing the exact extent of the disease, and the operative techniques for endometriosis are dependent upon the size, location of the implants and most important, the surgeon’s experience. At the same time, laparoscopy is the main treatment method. Surgery plays an important role in reducing the pain, improving the quality of life, restoring organ function and normal anatomy, as well as increasing/ improving fertility rate.
Various techniques and technologies have been described and used for the treatment of endometriosis. The techniques are divided into thermal ablation techniques and excision, using different tools, such as PlasmaJet, lasers, scissors, bipolar and monopolar electrosurgery, ultrasonic energy.
Endometriosis excision surgery aims to remove as much of the endometriosis tissues as possible, preserve the reproductive organs (where possible), repair the damage done by the disease and prevent/delay disease relapse. Jason Abbott noted that surgical treatment (excision) is an excellent option for patients with endometriosis and infertility.
According to him, surgery has a number of advantages for the often-symptomatic patients, and patients should be referred to a specialist center, in cases where the surgeon cannot remove the disease
Excision
Excision is the act of removing implants by cutting them away from the surrounding tissues/structures. During excision surgery, the endometriotic tissues are removed down to the roots with organs being reconstructed and their functionality restored.
Excision surgery requires extensive training, and the diagnosis and treatment of endometriosis are dependent on the surgeon’s ability to recognize the disease in all its different manifestations. Therefore, if the surgeon does not recognize atypical lesions or he/she is not familiar with the places where endometriosis can be found, then the disease will be missed and left untreated.
Excision doesn’t damage the tissues; therefore, a biopsy of the excised tissues can be obtained, confirming the diagnosis. When it is done by an experienced endometriosis specialist, excision surgery has a low rate of recurrence, reducing the symptoms and improving fertility, having a positive impact on the patient’s life.
Thermal ablation techniques
Thermal ablation technique also known as fulguration/ vaporization/ coagulation is a method whereby the endometriotic tissues are burned using heat, laser or cautery methods and can be done using different types of ultrasonic energy and laser.
Regarding the effectiveness of thermal ablation techniques on endometriosis, the studies done on the use of these two methods focus on the reduction of the symptoms and not on disease eradication. Since endometriosis can be very invasive, during surgical treatment using thermal ablation, healthy tissues cannot be separated from diseased tissues. Furthermore, all the disease is considered to be superficial, and the surgeon has no means of ensuring that all endometriosis of any depth of invasion has been eradicated.
This theory has not been disproven by research and it does not match the fact that endometriosis was found in young girls, men, fetuses, and animals. Based on the history of endometriosis, when Sampson published his first data, the term endometriosis did not exist. In 1921, Sampson published a study done on 23 women, and only 9 cases were histologically proved endometrial type ovarian cysts.
Excision VS Ablation
Excision doesn’t damage the tissues; therefore, a biopsy of the excised tissues can be obtained, confirming the diagnosis. When it is done by an experienced endometriosis specialist, excision surgery has a low rate of recurrence, reducing the symptoms and improving fertility, having a positive impact on the patient’s life.
The effectiveness of excising implants has been noted in clinical trials and through direct patients’ observation.
Both methods noted that excision of endometriosis resulted in fewer symptoms years after surgery in comparison with patients who underwent ablation surgery, and the symptoms returned within months.
Cases of advanced disease have a greater response to laparoscopic excision and a significant improvement in the symptoms of endometriosis.
Ablation may vaporize the surface of a lesion and still leave active disease below, and it is particularly true for deeply invasive nodules of the uterosacral ligaments. With ablation, active disease can remain in the pelvis and continue to cause pain. This method can cause more scarring and tissue damage, deep implants cannot be reached, and there are no tissues for pathology to confirm the diagnosis.
With ablation there is a possibility of accidentally damaging the underlying tissue, such as the bowel, bladder or ureter; therefore, implants that lie over vital organs, such as the bowel and large blood vessels are left untreated, resulting in higher recurrence more than 80% and further surgeries.