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Non-invasive Tools for the Diagnosis of Endometriosis
Table 1: Conditions with Overlapping Symptoms
Gynaecological Conditions Gastrointestinal Conditions Urinary Tract Conditions Mental Health Conditions
Endometriosis Irritable bowel syndrome Interstitial cystitis Somatisation
Adenomyosis Inflammatory bowel disease Painful bladder syndrome Substance abuse
Chronic pelvic inflammatory disease Diverticular colitis Recurrent urinary tract infection Physical and sexual abuse
Pelvic congestion (pelvic varicosities) Chronic intermittent bowel obstruction Radiation cystitis Depression
Pelvic adhesions Colon cancer Chronic urethral syndrome Sleep disorders
Leiomyoma Chronic constipation Urethral diverticulum
Post-operative peritoneal cysts Coeliac disease (sprue) Neoplasia
Ovarian neoplasms
The symptoms of endometriosis are non-specific, often overlapping with those experienced in a range of gynaecological, gastrointestinal and other conditions.
and/or oral contraceptives. The pain may progress and begin prior to Table 2: Occurrence of Pain at Different Stages
the onset of menses or become chronic and be noted throughout
of Endometriosis
most of the menstrual cycle. When rectovaginal or uterosacral
ligament involvement is noted, the pain is often felt in the rectum or
Stage of Endometriosis Occurrence of Pain (%)
lower back. Pelvic pain may be more common in women with deep,
I40
infiltrating implants:
9,10
the total number of implants has been found
II 24
to be associated directly with the intensity of dysmenorrhoea
III 24
IV 12
experienced in the last 60 days prior to laparoscopy,
11
as well as with
endometriosis location and infiltration depth.
12
In contrast,
Women with only minimal or mild involvement may manifest with pelvic pain in an elevated
percentage of cases.
dysmenorrhoea, pelvic pain and deep dyspareunia did not correlate
Source: Fedele et al., 1990.
13
with location when the lesion sites were evaluated as the ovary,
peritoneum and both ovary and peritoneum.
13
Finally, the site and the bladder wall, and ureteral endometriosis is almost always
depth of infiltration correlate with the type and severity of asymptomatic unless obstruction with hydronephrosis occurs.
symptoms, which may include dysmenorrhoea or chronic pelvic Characteristically, the symptoms may occur cyclically, with the
pain, deep dyspareunia, diarrhoea, dyschezia or bowel cramping.
14
symptoms noted above in addition to haematuria, flank pain and
In particular, severe deep dyspareunia and painful defecation during urinary tract infection.
19
menses are suggestive of posterior deep infiltrating disease,
15
while
dyspareunia is frequently associated with rectovaginal and Lung and chest-wall endometriosis usually presents with symptoms
uterosacral ligament disease. Fixation of the uterus or ovary by such as pneumothorax, haemothorax or haemoptysis associated
adhesions, especially if an endometrioma is noted, is also with menses.
20
associated with dyspareunia.
16
The controversy regarding whether endometriosis is a cause of
While genital tract involvement is the rule, endometriosis is also seen subfertility or an incidental finding is ongoing. An association between
in the gastrointestinal tract, urinary tract, lungs, scars and nerves. endometriosis and infertility has repeatedly been reported in the
Extrapelvic endometriosis may be asymptomatic or exhibit symptoms literature, but an absolute cause–effect relationship has yet to be
confirmed.
21,22
The mechanisms of infertility associated with
Endometriotic implants on the anterior
endometriosis remain controversial and likely depend, in part, on the
stage of the disease. Mechanisms include abnormal folliculogenesis,
cul-de-sac or bladder flap are elevated oxidative stress, altered immune function and hormonal
relatively common, and may give rise
milieu in the follicular and peritoneal environments and reduced
endometrial receptivity. These factors lead to poor oocyte quality,
to urinary symptoms such as dysuria, impaired fertilisation and implantation.
23
urgency, frequency, suprapubic pain
For women with ‘unexplained infertility’ who have not undergone
and dyspareunia. laparoscopy to confirm a diagnosis of endometriosis, lifestyle
changes, ovulation induction with clomiphene citrate and intra-
based on the organ system. The gastrointestinal tract is the most uterine insemination (IUI) are reasonable initial approaches to
common site of extrapelvic endometriosis. The rectovaginal septum achieving conception. If these interventions are unsuccessful,
with rectosigmoid involvement is thought to be the most common laparoscopy is appropriate to make/exclude the diagnosis of
form of extrapelvic endometriosis, and may present with intestinal endometriosis and initiate operative treatment (ablation, excision of
obstruction or symptoms such as pain, distension, diarrhoea, implants, lysis of adhesions). The second step is to consider the
constipation and rectal bleeding.
17
surgical resection of ovarian endometriosis, peritoneal endometriosis
and pelvic adhesions to restore pelvic anatomy and function. Whether
Endometriotic implants on the anterior cul-de-sac or bladder flap are surgery enhances pregnancy rates in women with moderate to severe
relatively common, and may give rise to urinary symptoms such as endometriosis is unclear.
24
There are no randomised prospective
dysuria, urgency, frequency, suprapubic pain and dyspareunia. These studies that demonstrate the efficacy of surgery in the treatment of
symptoms are noted to be similar to the symptoms of interstitial advanced endometriosis; however, it is believed that surgery may
cystitis.
18
Haematuria is a late sign and often denotes invasion through improve fertility in affected women.
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