To diagnose endometriosis we look for endometriosis symptoms.
Endometriosis can sometimes be diagnosed on pelvic examination. The gynaecologist may feel nodules of endometriosis at the top of the vagina and around the uterus or may suspect the presence of endometriosis by the fact that the uterus is tethered, rather than quite mobile, or that the ovaries are similarly tethered and perhaps tender to touch.
Rarely, we may see overt endometriosis in the vagina when we do a speculum examination, or sometimes nodules of endometriosis on the skin, such as in an old surgical wound.
Ultrasound Scans (USS) are unreliable for diagnosing endometriosis unless there is a cyst (endometrioma) in the ovary. X-rays, CT Scans and MRI are also not very reliable.
Laparoscopic surgery to diagnose endometriosis
Most endometriosis needs to be accurately and directly diagnosed by seeing it. This means that the patients need to have at least a minor form of surgery called a laparoscopy.
In this operation, a short anaesthetic (perhaps about 10 minutes) ensures that the patient feels no pain. A small incision is made in the umbilicus and then a telescope is inserted into the abdominal cavity to look carefully at all the pelvic organs and surfaces. In this way, endometriosis can be correctly identified and its severity assessed.
Various grading systems exist for endometriosis to assess its severity, from 1 (mild) to 4 (severe). Mild endometriosis generally just means a few spots scattered around the pelvis. Severe endometriosis usually implies significant adhesions and perhaps endometriosis with large cysts occurring in the ovary with subsequent damage. In between the two, we have moderate levels of endometriosis where the disease is extensive and has caused some pelvic scarring, but not to the level that we would define severe endometriosis.
Paradoxically, the severity of the endometriosis that we diagnose visually may not correlate well with the severity of the symptoms the patient is experiencing. Quite mild forms of endometriosis can cause quite severe pelvic pain, whilst some patients with very severe levels of endometriosis and extensive pelvic damage have had the endometriosis found by accident and have never really complained of the symptoms of endometriosis before.
Endometriosis can also be diagnosed at laparotomy. This is a far more significant operation than laparoscopy as a full-sized incision is made in the abdominal wall so the anaesthetic time is longer, the discomfort is greater and the recovery time is also longer.
Endometriosis diagnosis affects treatment plan
There is no substitute for an accurate diagnosis of endometriosis. It is a prerequisite to prescribe many of the drugs that we use to treat endometriosis. It is also worthwhile doing a “second look” laparoscopy at the end of the course of treatment to ensure that the endometriosis is adequately treated prior to ceasing therapy.
It seems illogical to place a patient on up to six months of drug therapy to cure a symptomatic and damaging condition and yet not check that the condition is cured prior to ceasing therapy. The other advantage of “second look” laparoscopy is that it is an ideal time, with most of the disease gone, for any residual disease to be treated surgically, such as by excising it with diathermy, or scissors.