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Updates in the Pharmacotherapy of Endometriosis - Episode 2

Approaching the Diagnosis of Endometriosis

Dr Hugh Taylor highlights the importance of early detection of disease and the use of imaging technology in the diagnosis of endometriosis.

Hugh Taylor, MD: There are terrible delays in our diagnosis of endometriosis today. It’s an average worldwide of 7 to 10 years between the time someone has symptoms associated with endometriosis and the time they receive that definitive diagnosis and get treatment. I think we can do better than this. I think early recognition is the key, awareness. This is a very hard thing for some people to talk about. Some of our patients are hesitant to talk about painful menses, painful intercourse, painful bowel movements, painful urination, which are all associated with endometriosis, but it’s important we ask our patients about this and be very open to hearing it. The other thing that’s hard to know is how painful periods can be considered endometriosis. The pain of menstrual cramps is really the only pain we as human beings have that we accept as normal. No other pain is considered something normal that we should accept. When someone first complains of dysmenorrhea, so often the response they get is, “Well menses are supposed to hurt, of course they hurt, just sort of toughen up or take a Motrin (ibuprofen).”

How do you know if your pain really is a lot more than what other people are experiencing? It’s very subjective. I think one of the first things we need to do to diagnose this early is to take this very seriously. Far too often it’s dismissed. I think we need to increase awareness about the disease so that people aren’t afraid to question whether their menstrual pain is abnormal. Often it gets to the point where it’s debilitating, where someone’s missing days of school or work before it gets recognized as abnormal pain. We need to have better ways to let people express their concern about dysmenorrhea and get them in for evaluation and treatment sooner. The other thing I think we need to do is start thinking about clinically diagnosing endometriosis. If someone has cyclic progressive pelvic pain, most likely that’s endometriosis. Rule out some of the other etiologies for pelvic pain, but most of the time that’s endometriosis. We may not feel any endometriosis on examination, we may not see it on imaging, but there’s nothing wrong with making that clinical empiric diagnosis and start thinking about treatment.

Endometriosis imaging has improved quite a bit. We’ve always been able to see endometriomas on ultrasound. I think one of the most important tools in diagnosing endometriosis is using ultrasound to rule out other potential causes of pelvic pain. Still, the vast majority of endometriosis we cannot see with imaging techniques. Superficial peritoneal endometriosis isn’t seen on ultrasound, it isn’t seen on MRI [magnetic resonance imaging], it is very hard to diagnose. So an important point is that when you see nothing on imaging, it doesn’t mean that somebody doesn’t have endometriosis. You can’t rule out endometriosis with imaging techniques. You can see those endometriomas, and we’re getting better at identifying deep infiltrating endometriosis with ultrasound or MRI. It’s not universally available yet, but I think we’re getting there so that we can see some of the more severe variants of endometriosis with imaging techniques. In my mind, I use it to find those endometriomas, and I use it to rule out other potential sources for pelvic pain: the tumors, the cysts, the hydrosalpinx, the infectious etiology, the adenomyosis, which we can see on imaging techniques. I rule out the other sources of pelvic pain, but you can never rule out endometriosis with any imaging technique.

Transcript Edited for Clarity