Introduction
Source: Dr Ma Li
This condition has been under recognised for many years. Most of the things we learnt 20 years ago has gone out of date.
- 10% of women at reproductive age
- 30% of subfertie women
- 40-60% of women with painful periods
- Awareness of the condition remains low
- An average delay in diagnosis of 7-8 years from the onset of symptoms
- The condition tends to progress
What is endometriosis?
- During fetal differentiation stage, some cells differentiate into the endometrial cells, and without hormone influence, it tends to remain quiet.
- It then grows and develop adhesions
Why delayed diagnosis
- Low public awareness
- Overlapping symptoms with many other conditions: IBS, IC, Chronic PID, pelvic adhesions, myofascial pain syndrome, pelvic congestion
- Medicl professionals
- Misconception in diagnosis and treatment
- Only 20% of endometriosis is found in the pelvic organs
- CT is not accurate enough to differenciate soft tissues
- MRI scan is good to differenciate: to order: endometriosis protocol, transvaginal and rectal gel
Endometriosis is not only a gynaecological condition
- Complex whole body disease that impact every system
History gives the best clue
How do we diagnose?
- History
- Physical examination: index finger into the vagina, and the middle finger into the rectum, to feel the pouch of douglas. Look for nodules and adhesions.
- Enzian score: P O T A B C Fa
Deep Endometriosis (Classic Enzian: Compartments A, B, C)
| Compartment | Location / Structure | Severity 1 (< 1 cm) | Severity 2 (1–3 cm) | Severity 3 (> 3 cm) |
|---|---|---|---|---|
| A | Rectovaginal space, retrocervical area, vagina | A1 | A2 | A3 |
| B | Uterosacral / cardinal ligaments, pelvic side wall (Left / Right) | B1 | B2 | B3 |
| C | Rectum / Rectosigmoid colon | C1 | C2 | C3 |
| Category | Code | Description | Severity / Size Grading |
|---|---|---|---|
| Peritoneum | P | Superficial peritoneal lesions | P1: Sum < 3 cm; P2: Sum 3–7 cm; P3: Sum > 7 cm |
| Ovary | O (L/R) | Endometriomas / ovarian surface foci > 5 mm | O1: Sum < 3 cm; O2: Sum 3–7 cm; O3: Sum > 7 cm |
| Tubo-Ovarian | T (L/R) | Adhesions & tubal mobility / patency | T1: Adhesions to pelvic wall; T2: Adhesions to uterus; T3: Adhesions to USL / bowel |
| Deep Endometriosis | A, B, C | Deeply infiltrating lesions | 1: < 1 cm; 2: 1–3 cm; 3: > 3 cm |
| Extragenital & Other | F | Further specific localizations | FA: Adenomyosis; FB: Bladder; FU: Ureter; FI: Bowel; FO: Other |
Diagnostic Prefix Legend
| Prefix | Modality |
|---|---|
| #Enzian (u) | Ultrasound assessment |
| #Enzian (m) | MRI assessment |
| #Enzian (s) | Surgical / Intraoperative assessment |
Treatment counselling
- Hormone or Surgical or Fertility
- The treatment decision is mainly based on the lifecycle of the patient
- Consider egg freezing
- Dienogest (Visanne) (POP): ADR: mood swing, irregular spotting 90%, weight gain, hair loss
- Counselling is key to ensure compliance for treatment
- Risk of breast cancer is very very low, advice regular screening
- Risk of thrombosis: more in those with estrogen, however in those POP, would be low, mainly in patients with risk of VTE
- Risk of osteoporosis: Long term, have to watch for bone health: to advice calcium supplementation
Surgery
- Ablation VS excision
- Laparoscopy should not be used purely for diagnosis of endometriosis
- USS mapping for endometrosis