Diagnosis

Likely diagnostic investigations:

• Internal gynaecological examination
• Ultrasound and MRI
• Laparoscopy

During the internal vaginal examination, the doctor will try to feel and see any deposits of endometriosis. For some that may mean feeling endometriosis behind the cervix, between the womb and the rectum and in the ligaments around the cervix. An enlarged ovary can also be felt during examination. Sometimes, the gynaecologist may perform a rectal examination in order to feel endometriosis between the rectum and the cervix/womb. For (particularly young) women such an examination can be emotionally stressful and in such cases we move directly to radiological examination by ultrasound and/or MRI.

An ultrasound or MRI examination can be very valuable in helping to demonstrate or out rule more severe endometriosis. Both investigations have advantages and disadvantages.

Advantages and disadvantages of ultrasound

One of the advantages of ultrasound is that it is available in almost every gynaecological practice. The disadvantage is that the result is very dependent on the specific knowledge and experience of the one doing the examination; such special knowledge of the ultrasound appearances of endometriosis is required for a reliable diagnosis. Also the use of the ultrasound is limited to the organs in the pelvis.

MRI examination at Endometriose in Balans

The advantage of an MRI examination is that it is able to look at all of the organs in the abdomen. In addition, it is possible to visualise other sites of endometriosis not otherwise visible. The disadvantage of an MRI specifically to look for endometriosis is that it cannot be performed directly at the time of the clinic appointment and the specific examination required is not available in every hospital. Also, there are some patients with claustrophobia who find the examination too stressful and in which it therefore cannot be done. The test is also adversely affected by any movement of the patient or even of her internal organs such as bowel.

In order to obtain good MRI images it is essential to minimise movement of the bowel and to have the bowel empty. On account of this you will receive a prescription for a tablet to be taken three hours before your scheduled appointment.

We also request that you have nothing to eat in the four hours prior to the examination and drink only clear, non-fizzy drinks.

A diagnostic laparoscopy involves looking inside the tummy with a telescope under anaesthesia. With this, superficial deposits of endometriosis (relatively low grades) can be seen which are not visible on ultrasound or MRI. Depending on their size and site these may be readily removed. One may also see the more advanced stages of endometriosis. The management of the latter disease of often much more complex and can only be performed after extensive counselling. The value of diagnostic laparoscopy is also highly dependent on the knowledge and experience of the surgeon and especially so for endometriosis.

A laparoscopy can therefore be useful in the establishment of a diagnosis of endometriosis. However, the quality and value of the investigation is very dependent on the knowledge and experience of the doctor in charge. Without such experience it is easy to miss even severe endometriotic disease.

After the investigations you will get to hear if you are likely to have endometriosis and in what form and what grade. Following this you will be advised on the treatment possibilities. This may be documented and explained by means of a hand drawing.

Different form of endometriosis include:

• Adenomyosis
• Endometriosis, grades 1and 2
• Endometriosis, grades 3 and 4

Adenomyosis
Adenomyosis is a form of endometriosis whereby the lining tissue of the womb extends outward into the surrounding muscle. This benign condition responds to female hormones (oestrogen and progesterone) in the same manner as the tissue in the lining of the womb, namely becoming thicker during the menstrual cycle, breaking down and bleeding.

Endometriosis, grade 1 and 2
By grades 1 and 2 endometriosis we refer to mainly superficial rather than deeply invasive endometriosis and in most cases such disease is not visible on ultrasound or MRI investigations.

Endometriosis, grades 3 and 4
By grades 3 and 4 endometriosis we refer to deeply invasive disease. This is normally evident on ultrasound and MRI examinations.