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    Endometriosis – Diagnosis

    Obstetrics and Gynecology

    Last Updated Dec 05, 2020
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    Context

    • Defined by the presence of endometrial tissue (glands and stroma) outside of the uterine cavity.
    • Affects 6 to 10% of women of reproductive age, 50 to 60% of women and teenage girls with pelvic pain, and up to 50% of women with infertility.
    • The most common cause of secondary dysmenorrhea in adolescents, with a mean age of presentation 25-30.
    • Often the clinical starting point is ruling out critical diagnoses – ruptured ectopic, ovarian torsion, pelvic inflammatory disease, hemorrhagic ovarian cyst.
    • Can be a chronic relapsing disorder that necessitates long term follow up. Ensuring adequate follow up after discharge from the ED is crucial.

    Diagnostic Process

    Diagnosis:

    • Endometriosis is definitively diagnosed by histologic evaluation of a lesion biopsied during surgery.
    • A combination of symptoms, signs, and imaging findings can be used to make a presumptive, nonsurgical diagnosis of endometriosis and start initial treatment. Studies have reported an average delay of 7 to 12 years for definitive diagnosis in women with endometriosis.

    Key Differential Considerations:

    • Endometriosis can cause chronic, acute and acute on chronic pelvic pain.
    • Acute pelvic pain in the context of endometriosis could suggest a ruptured endometrioma or ovarian torsion (increased risk from pelvic mass).
    • Other critical differential diagnoses include a ruptured ectopic pregnancy, pelvic inflammatory disease and a hemorrhagic ovarian cyst.

    Presentation:

    • Suggested by the triad of dysmenorrhea, dyspareunia and dyschezia.
    • Heavy menstrual bleeding.
    • Pelvic mass.
    • Less common symptoms include: bowel/bladder dysfunction and back pain, pneumothorax.
    • Risk factors include 1st degree family history, prolonged exposure to endogenous estrogen (early menarche, nulliparity, late menopause, or obesity).

    Physical:

    • Often normal; lack of findings does not exclude the disease.
    • Supportive findings include tenderness on vaginal examination, nodules in the posterior fornix and adnexal masses.

    Investigations:

    • There are no pathognomonic laboratory findings for endometriosis.
    • Ca 125 levels are currently not recommended.
    • Beta-HCG should be done in any female of childbearing age with pelvic pain.
    • Further labs should be guided by your differential diagnosis.

    Imaging:

    • Pelvic US (ensure follow up organized if performing as outpatient) acutely if torsion or ectopic under consideration.
    • Consider MRI for refractory/atypical cases or if considering thoracic endometriosis.

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