Diagnosis

Let’s start with the basics…

One of the most frequent questions we get is

“How do I know if I have endometriosis?”.

Being diagnosed with endometriosis is often more difficult than expected. The estimated time is 7-8 years, on average.

Before illustrating the 5 steps required to diagnose endometriosis, we would like to inform you that, some years ago, we created a rapid online test. It does not serve as a diagnostic tool but can help to identify the first red flags and understand whether one should see a specialist or go to a specialized centre.

If you want to do the online test developed by the Italian Endometriosis Foundation,
CLICK HERE

Various exams are required to diagnose the endometriosis condition and, sometimes, if you don’t go to a specialized centre the symptoms might be confused with those of other diseases.

Here, we try to summarize the diagnosis protocol for endometriosis. However, each centre may adopt a different approach. Below are some steps that could contribute to give you an idea of what to expect.

The 5 steps to diagnose endometriosis

1. First appointment with a doctor: illustrate all your symptoms to the gynaecologist. A quick questionnaire is often included to understand the present condition of the patient. To be prepared for this first consultation, you should record your pain and its localization starting from the week before. For this purpose, we could use a pain map (here you can find a downloadable version), which is easy and quick to fill in; it represents a guide to help you explain your condition.
2. Gynaecological examinations (vaginal and rectal) to evaluate the presence of endometriosis in the lower pelvic region.
3. Magnetic resonance imaging and blood tests: according to the results of the previous exams, the doctor may order a specific magnetic resonance exam and/or blood tests. Don’t worry, your gynaecologist will tell you exactly what to do.
4. Evaluation and diagnosis: after the completion of the prescribed tests, a new appointment will be set so that the gynaecologist will evaluate the results and provide you with a diagnosis.
5. Treatment definition: after the second visit, the doctor, if the endometriosis condition has been diagnosed, will indicate the treatment plan to follow or, in certain cases, the surgical intervention required.

• How to contact us: you can call us every weekday (Monday–Friday) from 10 am to 6 pm at our contact numbers to receive extensive information about endometriosis and our services, as well as to request an appointment.

Diagnostic tests:

Below are summarized the diagnostic tests usually prescribed in the case of suspected endometriosis. All the tests listed here can be performed at the Italian Endometriosis Centre thanks to modern technologies, a safe methodology and a specialized staff.

 

Bimanual examination:

Bimanual (gynaecological and rectal) examinations are crucial to assess deep pelvic endometriosis, which causes fibrotic retraction of the perivaginal and pericervical tissues and, sometimes, the formation of solid nodules in the lower pelvic area.

Since these consequences usually do not have a cystic or vacuolar form, they cannot be observed through diagnostic imaging and, thus, are not revealed by radiological tests (transvaginal echotomography and nuclear magnetic resonance). Deep lesions occur frequently in endometriosis patients.

 

LABORATORY TESTS

Endometriosis can occasionally increase the serum levels of some antigens (CA 125, CA 19.9, etc.), leading to their positive results in laboratory blood tests. This positivity is not constant nor observed in all the patients. If there are positive markers, the endometriosis condition is certain; in contrast, negative markers cannot exclude completely the disease since about 50% of the endometriosis patients exhibit negative results for serum markers. The endometriosis diagnosis procedure must always include these markers.

 

IMAGING

Heterotopic location of the endometrial tissue responding to hormonal stimuli.
The transvaginal/transrectal ultrasound is highly accurate in the endometriosis diagnosis, but its ability to determine the disease staging is still unclear.
Some authors have validated the magnetic resonance imaging (MRI) technique for the observation of millimetric implants of the disease in the peritoneum by using sequences of signal suppression for the adipose tissue.

 

TRANSVAGINAL ULTRASOUND

– Background: if performed by an expert, ETV can attain high diagnostic accuracy, but it is only a first-level examination.
– Patient preparation: intestinal preparation not required.
– Technical equipment: transvaginal probe (broad-band transducers, 5–9 MHz), 3D reconstruction.

DEEP ENDOMETRIOSIS: DIAGNOSIS

In deep endometriosis, the disease is localized in the retroperitoneum and the pelvic connective tissue or the walls of the pelvic organs. At the peritoneum level, the disease can infiltrate deeply the organs’ walls, directly or indirectly damaging even the organs themselves.

Deep endometriosis histologically differs from the disease with superficial or intermediate localization. Its histology presents fibromuscular hyperplasia and a fibrous, vascular and nervous reaction, followed by the formation of nodules.

If it invades the bladder, it is called “anterior endometriosis”. “Posterior endometriosis”, instead, includes different localizations: uterosacral ligaments, ureters, rectum and vagina. The depth of parietal invasions and, especially, the localization of deep endometriosis determine the pain intensity. Surgery is still the most recommended treatment. For a complete exeresis of the disease, an accurate and precise preoperative preparation is paramount to determine the correct endometriosis staging.

 

MAGNETIC RESONANCE IMAGING

– Background: MRI provides high diagnostic accuracy about the extent of deep endometriosis (Bazot et al., Radiology 2004).
– Patient preparation: intravenous muscle relaxant (Buscopan), fluid distension of the sigma-rectum pouch (not always) and moderate bladder distension.
– Technical equipment: high-field magnets, phased-array coils, TSE T1 HR (3 mm), T1 FLASH and T1 SE FS sequences and contrast media (in selected cases).

The endometriomas appear hyperintense in the T1-weighted images and moderately hypo or hyperintense in the T2-weighted ones. Chronic bleeding and the resulting accumulation of iron and proteinaceous material in the endometriomas lead to the phenomenon called “shading”. The fat suppression technique enables the distinction between cysts with hematic and adipose content (endometriomas and dermoid cysts, respectively) and improves the diagnosis of small implants. A contrast medium is recommended to characterize wall nodules, evaluate the inflammatory reaction and study the not dilated urinary tracts.

 

RADIOLOGIC DIAGNOSIS

Fibrotic nodule (13 mm) with haemorrhagic spots in the rectovaginal septum and extensions at the vault level and above the Douglas level. Axial and sagittal T2 and TSE images: inhomogeneous hypointense mass in the rectouterine pouch and asymmetric thickening of the anterior rectal wall, drawn towards the torus uterinus.

The T1 images, with the fat suppression, show the haemorrhagic spots in the lesion area.

 

DIAGNOSTIC CRITERIA

Vagina: vault thickening or cystic areas.
Rectovaginal septum: retroperitoneal nodule below the lower cervix edge.
Ureteral involvement: between 0,01% and 1%.
TSE Te: (a,b) endometriosis of the septum, with (arrows in c and d) Douglas pouch obliteration and involvement of dilated ureters.

 

Reasons to opt for magnetic resonance

• Completion of the preliminary gynaecological examination
• Evaluation of the anterior and posterior pelvic space for the preoperative preparation
• Surgical planning
• Observation of the adhesions
• Assessment of possible hydroureteronephrosis
• Contrast medium use in the case of suspected disease degeneration
• Experienced operator
• Appropriate technology

For further information about operations and specific exams, contact us.