Women's Health

Endometriosis: Diagnosis, Stages & Treatments

Our previous article discussed the possible causes and symptoms of endometriosis. If you suspect that you have the symptoms listed, see your gynaecologist for an assessment. Left untreated, endometriosis may worsen with time. 

Diagnosis Of Endometriosis

The doctor can help by:

Screening For Your Symptoms

Guided questioning will help review if you have endometriosis symptoms such as painful menstruation, urinary discomfort, bowel problems or pain during sexual intercourse. This can allow the doctor to order the relevant investigations. A thorough assessment will also include questions about your health, family history of the disease and desire for fertility.

Conducting A Pelvic Exam

The pelvic exam may involve feeling of the reproductive organs which require an internal palpation through the vaginal wall and cervix and a counter pressure on the lower abdomen with the other examining hand. This allows the doctor to feel for areas of scarring or swelling as well as identify painful spots caused by potential endometriotic nodules/ scars forming.

Beside Ultrasound Scan

An ultrasound will be performed during the consultation to provide visual information on possible cysts and pelvic organs that are associated with endometriosis. There is no radiation involved with ultrasound as sound waves are used for the generation of images. The scan may suggest the presence of endometriosis which can be further explored either by an MRI pelvis or diagnostic laparoscopy (keyhole surgery).

When it comes to ultrasound tests, it is important to check your bladder status. Your bladder needs to be empty for a transvaginal ultrasound, so make sure to use the toilet right before the exam and it should be full for an abdominal ultrasound (have 3-4 glasses of water prior to the exam).

More detailed assessment can be in the form of an MRI pelvis or laparoscopy

MRI Pelvis

This investigation uses a magnetic field and radio waves to create detailed images of the organs and tissues within your body. There is no radiation involved. This investigation can give a very detailed view of how the endometriosis implants and scarring tissue within the pelvis – for the complex endometriotic cases, it can help with surgical planning. Certain cases of endometriosis can involve surrounding organs like the bladder or rectum – and may need the expertise of another specialist during the surgery.

Laparoscopy

This is a surgery conducted under general anaesthesia where a small camera attached to a telescope is inserted through a small incision in the abdomen to inspect the pelvic area. This can give a definitive diagnosis of the location, extent and size of the implants. Operative ports allow treatment to be performed at the same time once the diagnosis is seen – in the form of endometriotic implant excision (removal); ablation and cyst removal. The tissue removed from the body is sent for microscopic examination (histology).

Endometriosis Stages

Once diagnosed, endometriosis can be classified into one of four stages. The most widely used scale is from the American Society of Reproductive Medicine which assigns points according to the spread of the endometrial tissue, its depth, and the areas of the body affected.

These are the four stages of endometriosis:

1. Minimal: Few small shallow implants with little or no scar tissue.
2. Mild: More lesions with adhesions and scarring as compared to stage 1.
3. Moderate: Visible adhesions and deep implants. Presence of small blood cysts on ovaries.
4. Severe: Presence of endometriosis on most pelvis surfaces with deep implants and thick adhesions.

This staging of endometriosis will require either MRI or surgery to confirm, usually the latter.

Although this staging separates patients into different “stages”, some patients may have very severe symptoms despite being in a lower stage. Hence the need for personalised diagnosis and treatment to enable the patient to have an optimal quality of life, and relief of pain and discomfort caused by the condition.

How To Treat Endometriosis?

Endometriosis is an estrogen dependent chronic disease. Hence the medical treatment aims to use hormonal manipulation to suppress the lesions. As the pain of endometriosis is due to deep infiltration, adhesions and scarring, the surgery approach aims to remove the lesions and free the scarring.

The type and combination of therapy used will be determined by factors such as – age of the patient, desire for fertility, severity and location of lesions and how the symptoms affect the quality of life.

Here is an overview of the various forms of treatment available:

Pain Killers

Non-steroidal anti-inflammatory medications like Ibuprofen, Synflex or Arcoxia can help suppress prostaglandin production. Prostaglandin is a chemical produced by the body which can cause swelling and pain during menstruation – leading to the typical cramps and discomfort. Hence, this class of medication is more effective than paracetamol. Start this medication on the first day or just before the flow of menstruation for maximal effectiveness.

Hormone Therapy

It treats endometriosis by controlling the hormonal fluctuations in the menstrual cycle. By keeping the hormonal levels steady – this can help prevent new or additional lesions.

There are different hormonal methods available:

Birth Control Pills

For patients who desire contraception, this can help prevent ovulation and spikes in the hormonal levels. Two to three cycles of pills can also be taken at a time – allowing bleeding only every 2-3 months. This means the patient can avoid the period entirely and the pain with it.

Gonadotrophin Releasing Hormone (GnRH) Agonist

This treatment puts the body into artificial menopause and lowers the hormonal levels, effectively putting endometriosis to “sleep”. This can allow the endometriosis to thin down during the treatment period and hopefully reduce the active lesions when treatment is over. Due to the side effects of menopause with this therapy – including bone-thinning effects which may be long-lasting, it can only be used for about 6 months. If used for more than 6 months, hormonal replacement therapy will be required.

Progestin Therapy

Progesterone is a hormone that can slow down endometriosis progression. The therapies may include an intrauterine device with levonorgestrel (Mirena), contraceptive implant (Implanon), contraceptive injection (Depo-Provera) or progestin pill (Visanne).

These can halt menstrual periods and the growth of endometrial implants, which may relieve endometriosis signs and symptoms. Prolonged use is possible, unlike GnRH agonists.

While medication can control symptoms, they are generally good for patients with mild to moderate endometriosis related symptoms or after surgery for reduction of recurrence. You should consult your gynaecologist and weigh the pros and cons of each treatment.

Surgery although invasive, has proven to help with endometriosis related pain particularly for severe lesions and patients who desire fertility.

Surgical procedures

Laparoscopy

Using a telescope inserted through a tiny incision in the umbilicus, the surgeon is able to magnify and inspect the pelvic surfaces and diagnose endometriosis. The implants and lesions such as can be surgically removed, adhesions and scarring freed, and the integrity of the fallopian tubes checked. The advancement of telescopes and cameras has made this procedure the surgery of choice for precise excision of lesions. Laparoscopic surgeries also allow patients to have faster recovery, with less surgical-related pain and bleeding.

Robotic assisted laparoscopy

Apart from all the advantages that a conventional laparoscopy can offer, it gives the surgeon the extra edge when it comes to deep pelvic surgery. A more precise movement to allow the surgeon to perform surgical excision without tremors. In very severe cases, such as deep infiltrating endometriosis lesions involving the intestine, ureters and bladder, excision of the affected areas can be achieved safely and accurately, hence reducing the risks of surgical related complications.

Hysterectomy

For patients with severe endometriosis and adenomyosis, who no longer want children, a hysterectomy may be offered. The ovaries may be removed at the same time if they are affected by the condition. Removal of the womb eliminates monthly periods but does not affect hormonal status. Removal of the ovaries will render the patient menopausal but will address the endometriosis disease and pain-related symptoms.