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Laboratory Tests and Ancillaries
Urinalysis and urine culture are used to identify pain originating
in the urinary tract (eg cystitis, stones). Pregnancy tests and tests for
sexually transmitted infections (STIs) like gonorrhea and chlamydia, when appropriate,
are also utilized.
Laparoscopy
Laparoscopy is the gold standard for diagnosis unless lesions are
visible in the vagina. It may also be used for therapeutic purposes. It should
not be done during or within three months of hormonal treatment to avoid underdiagnosis.
Biopsy and histopathologic study of at least one lesion is ideal. The
three cardinal features (ie ectopic endometrial glands, ectopic endometrial
stroma, hemorrhage into adjacent tissue) should be present. In adolescents, the
features of endometriosis may be atypical (ie clear vesicles, red lesions).
A negative laparoscopy does not exclude the diagnosis of
endometriosis. Depending on the severity of the disease found, it is best to
remove the endometriotic lesion at the same time. Differential diagnoses can be
excluded by biopsy.
Laparoscopic Classifications
The Revised American Society for Reproductive Medicine (rASRM)
Score (formerly the Revised American Fertility Society [rAFS] Score), which is
based on the location, extent and severity of lesions, noted aspects including
bilaterality, depth of invasion, size, involvement of the ovary and cul-de-sac,
and density of adhesions. It does not take into account the retroperitoneal
structures and deep infiltrating endometriosis. Scoring is as follows:
- 1-5 for minimal disease (stage I)
- 6-15 for mild disease (stage II)
- 16-40 for moderate disease (stage III)
- >40 for severe disease (stage IV)
The Enzian Staging System takes into account the presence of deep
infiltrating endometriosis. It supplements the rASRM score with a description
of deep infiltrating endometriosis, retroperitoneal structures, and other organ
involvement.
Serum CA-125
Women with endometriosis may have high serum CA-125 concentrations.
It has no value as a diagnostic tool in endometriosis, though it may be used to
assess the presence of an undiagnosed adnexal mass. It is also elevated in
ovarian epithelial neoplasia, myoma, adenomyosis, acute pelvic inflammatory
disease (PID), ovarian cyst, and pregnancy.
Biopsy
A biopsy may be considered in suspected endometriosis lesions and
endometriomas to help confirm the diagnosis and exclude possible malignancy. It
is recommended for the diagnosis of patients with mild to moderate
endometriosis. In patients with endometriosis, the prevalence of ovarian cancer
is <1%.
Imaging
Transvaginal Sonography (TVS)
Transvaginal sonography is considered the first-line imaging tool
to examine suspected endometriosis. It should be performed to determine whether
a pelvic mass or structural anomaly is present. It is useful in diagnosing or
excluding rectal endometriosis.
It may identify an ovarian endometrioma and help identify other
structural causes of pelvic pain, such as ovarian cysts, torsion, tumors,
genital tract anomalies, and appendicitis. It also distinguishes endometrioma
from other ovarian cysts with 83% sensitivity and 89% specificity. Ovarian
endometrioma may be diagnosed in premenopausal women with findings of ground
glass echogenicity, one to four compartments, and the absence of papillary
structures with blood flow.
Magnetic Resonance Imaging (MRI)
MRI may be helpful in some cases to better define an abnormality
suspected by sonography. It detects ovarian endometrial cysts with 90%
sensitivity and 98% specificity. It provides the exact location of the deep
retroperitoneal lesion and is useful in ruling out other pelvic organ
involvement such as bowel or bladder. It may be used as part of a pre-operative
workup but should not be used as first-line.
Computed Tomography (CT) Scan
CT scan may show the size and different characteristics and densities
of adnexal masses. It is used to evaluate other pathology or organ involvement.
Chest CT is useful for thoracic endometriosis.
Other Imaging Studies
Cystoscopy, colonoscopy, and rectal ultrasonography may be
required if deep endometriosis is suspected.