Severe dysmenorrhoea, urinary pain help predict deep infiltrating endometriosis

Severe dysmenorrhoea, pain related to urinary and gastrointestinal tracts, higher fertility desire and infertility rate are all associated with deep infiltrating endometriosis, according to a Singapore study. On the other hand, heavy menstrual bleeding is predictive of adenomyosis.

“Patients with pain symptomatology and subfertility should be referred early to a tertiary centre with the capability to diagnose and manage deep infiltrating endometriosis,” the researchers said.

Using the Table of Surgical Procedures coding, the researchers accessed the database of the National University Hospital in Singapore and identified patients undergoing index surgery for endometriosis or adenomyosis from 2015 to 2021. They then compared social and epidemiological features of those diagnosed with endometrioma only, adenomyosis only, and deep infiltrating endometriosis.

Finally, independent risk factors for deep infiltrating endometriosis compared with endometrioma only were identified by entering significant variables from univariate analysis into three binary multivariate logistic regression models.

Overall, 259 patients met the inclusion criteria, of whom 59 had ovarian endometrioma only, 47 adenomyosis only, and 152 deep infiltrating endometrioses. [Ann Acad Med Singap 2023;52:71-79]

Deep infiltrating endometriosis correlated with higher rates of severe dysmenorrhoea (odds ratio [OR], 2.80, 95 percent confidence interval [CI], 1.02‒7.70) and out-of-pocket private surgical care (OR, 4.72, 95 percent CI, 1.85‒12.04) when compared to endometrioma only.

Likewise, deep infiltrating endometriosis correlated with a higher fertility desire (OR, 13.47, 95 percent CI, 1.01‒180.59) and a lower body mass index (OR, 0.89, 95 percent CI, 0.79‒0.99) when compared to adenomyosis only. On the other hand, heavy menstrual bleeding occurred more frequently in those with adenomyosis.

“The most prominent hallmark of deep infiltrating endometriosis was pain,” the researchers said. “Compared to endometrioma only or adenomyosis only, cases of deep infiltrating endometriosis suffered more severe dysmenorrhoea, dyspareunia, dyschezia, tenesmus, and diarrhoea.”

Diagnosis delay

Notably, the duration between diagnosis and surgery were almost double among patients with deep infiltrating endometriosis compared to those with endometrioma only. They were also more likely to undergo a private class of surgery despite this method being more expensive in Singapore, which has an out-of-pocket funded healthcare system.

“The diagnostic delay in endometriosis is not new,” the researchers said. “The awareness of long delays in the diagnosis of endometriosis and unsatisfactory treatments were first raised in the 1980s by researchers in the US, and subsequent studies on more than 7,000 endometriosis patients showed the average time to diagnosis was 9 years.” [Best Pract Res Clin Obstet Gynaecol 2004;18:201-218]

However, there have been efforts made in public education and primary care consultation to speed up the identification of symptoms and treatment of patients. [Am J Obstet Gynecol 2019;220:354.e1-e12; Eur J Obstet Gynecol Reprod Biol 2008;139:111-115; Qual Health Res 2008;18:522-534; J Psychosom Obstet Gynaecol 2021;42:174-180]

“The longer duration between the diagnosis of deep infiltrating endometriosis and the index operation in our study further demonstrated the delay in receiving treatments and indicated the underlying challenges in providing care for this most debilitating form of endometriosis,” the researchers said.

“Patients with severe pain symptomatology should be referred to a tertiary centre with the ability to diagnose and manage deep infiltrating endometriosis as this may frequently require complicated excisions of endometriotic deposits affecting the urinary or gastrointestinal tracts,” they added.