Endometriosis is the presence of endometrial-like glands and stroma outside the uterus. It is a common cause of abdomino-pelvic pain, adnexal mass, and infertility in reproductive-age women. Endometriosis affects an estimated 10% to 20% of reproductive-age women and up to 70% to 90% of patients with chronic pelvic pain.1-3 Several theories exist regarding the pathogenesis of endometriosis, with the most widely accepted being Sampson’s retrograde menstruation.4,5 However, all theories have gaps, thus the exact pathophysiology of endometriosis remains enigmatic.
Although hormonal management and surgery offer symptomatic relief, a cure for endometriosis continues to be elusive. Maneuvering through obstetric care, annual gynecologic visits, and the myriad of problem visits in a busy generalist practice is already challenging, and undertaking a thorough evaluation and management of endometriosis often leads to frustration to both patient and provider.
Ob/gyns should be prepared to have a lasting relationship with women with endometriosis because the condition is chronic and has no known cure. It is important to bear in mind that most patients have been dealing with pain for years prior to diagnosis, with a mean time of 7 to 11 years delay in diagnosis of endometriosis.6 The common 15- to 20-minute allotted time for a new patient consult will be wholly inadequate for an initial evaluation. To expect to review the pages of outside records that patients often have, obtain a comprehensive history, perform a detailed exam, and initiate an assessment/plan in this limited time is a set-up for patient and physician dissatisfaction.
Some changes to practice and communication go a long way. If possible, schedule all new pelvic pain or endometriosis consults for 30 minutes. When patients are scheduling their appointments, they should be asked to send any records over for review prior to the consult. This allows for focusing on the visit rather than scanning rapidly through pages of records during the allotted time.
It is important to acknowledge the patient’s symptoms and the fact that they may have been present for a long time, while noting that it is unlikely that a solution will be available at the first consult. If outside medical records are available and have been reviewed, let the patient know that you have thoroughly reviewed them and are familiar with the location of her pain, aggravating factors, and prior medical and or surgical management. This allows for a focused and guided history that optimizes the consult time.
If a detailed history of a patient’s symptoms is not available via outside records, then ask her about cyclic/noncyclic pain, pain with urination, pain with bowel movements, presence and site of pain with intercourse, bloating, fatigue, and disruptions in quality of life. Questions should also be asked to discern other potential causes of pelvic pain, including non-endometriosis gynecologic pain, gastrointestinal, urinary tract, musculoskeletal, psychological, and neurologic. Follow this with a detailed abdominal and pelvic exam. The pelvic exam should include a Q-tip evaluation of the vulva, single-digit vaginal exam to assess levator ani, obturator internus, piriformis, bladder, urethra, vaginal fornices, and uterosacral ligaments. A bimanual exam should then be performed, followed by a rectovaginal exam. Sometimes due to time constraints or inexperience with pelvic pain-centered exam, the pelvic exam portion of a patient’s note is normal and reads like a standard template. While this may, in fact, be the case, pertinent negatives of the exam components described above should be included.
The author reports no potential conflicts of interest in regard to this article.
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