Why are there delays in the diagnosis of endometriosis?
Diagnosing endometriosis relies on identifying flags on physical exam
Physical examination findings that raise the likelihood that the patient has endometriosis include:
- fixed and retroverted uterus
- adnexal mass
- lesions of the cervix or posterior fornix that visually appear to be endometriosis
- uterosacral ligament abnormalities, including tenderness, thickening, and/or nodularity14,15
- lateral displacement of the cervix (FIGURE 2)16,17
- severe cervical stenosis.
In one study of 57 women with a surgical diagnosis of endometriosis, uterosacral ligament abnormalities, lateral displacement of the cervix, and cervical stenosis were observed in 47%, 28%, and 19% of the women, respectively.17 In this same study 22 women had none of these findings, but 8 had a complex ovarian mass consistent with endometriosis.
The possibility of endometriosis increases as the number of history and physical examination findings suggestive of endometriosis increase.
Related article:
Endometriosis and pain: Expert answers to 6 questions targeting your management options
When transvaginal ultrasound can aid diagnosis
Most women with endometriosis have normal transvaginal ultrasonography (TVUS) results because ultrasound cannot detect small isolated peritoneal lesions of endometriosis present in Stage I disease, the most common stage of endometriosis. However, ultrasound is useful in detecting both ovarian endometriomas and nodules of deep infiltrating endometriosis (DIE).18 TVUS has excellent sensitivity (>90%) and specificity (>90%) for the detection of ovarian endometriomas because these cysts have characteristic, homogenous, low-level internal echoes.19,20 For the diagnosis of DIE of the uterosacral ligaments and rectovaginal septum, TVUS has fair sensitivity (>50%) and excellent specificity (>90%).21 In most studies, magnetic resonance imaging performs no better than TVUS for imaging ovarian endometriomas and DIE. Hence, TVUS is the preferred imaging modality for detecting endometriosis.22
- Endometriosis is a common gynecologic disease. Approximately 8% of women of reproductive age have the condition.
- Many patients report lengthy delays between the onset of symptoms of pelvic pain and the diagnosis of endometriosis.
- Both patients and clinicians contribute to the delay in the diagnosis of endometriosis: Women are often reluctant to report the severity of their pelvic pain symptoms, and clinicians often under-respond to a patient's report of severe pelvic pain symptoms.
- First-line therapy for the treatment of moderate to severe dysmenorrhea is nonsteroidal anti-inflammatory drugs and estrogen−progestin contraceptives.
- Increasing vigilance for endometriosis will shorten the time between onset of symptoms and definitive diagnosis.
- Reducing the time between the onset of symptoms and diagnosis of endometriosis will improve the quality of life of women with the disease because they will receive timely treatment.
This is a practice gap we can close
Clinicians take great pride in accurately solving patient problems in a timely and efficient manner. Substantial research indicates that we can improve the timeliness of our diagnosis of endometriosis. By acknowledging patients’ pain symptoms and recognizing the myriad symptoms and physical examination and imaging findings that are associated with endometriosis, we will close the gap and make this diagnosis with greater speed.
Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.
