Clinical and surgical diagnosis of endometriosis, with Heather Appelbaum, MD

Recognizing when to make a pattern-based clinical diagnosis of endometriosis, rather than defaulting to surgical confirmation, can help clinicians intervene sooner and relieve patients' symptoms more quickly, according to Heather Appelbaum, MD, FACOG, director of Pediatric and Adolescent Gynecology at K. Hovnanian Children's Hospital at Hackensack Meridian Jersey Shore University Medical Center, associate professor of Obstetrics and Gynecology at Hackensack Meridian School of Medicine, and director of the PMOS Multidisciplinary Program at Jersey Shore University Medical Center.

Speaking about her presentation “Multimodal Treatment for Endometriosis,” delivered this year at the North American Society for Pediatric and Adolescent Gynecology (NASPAG), Appelbaum described a talk built around two central aims.

“It was really twofold. One was to understand the difference between a clinical diagnosis and a surgical diagnosis of endometriosis and when it is indicated to make a pattern-based clinical diagnosis versus a surgical diagnosis, and the second overarching goal of the presentation was to discuss the multimodal treatment approach to endometriosis,” she said.

A pattern-based diagnosis

Appelbaum emphasized that keeping endometriosis on the differential for abdominal and pelvic pain supports earlier intervention, and that its presentation is highly variable.

“The focus on a pattern-based diagnosis equals understanding that pelvic pain can present in many different ways, meaning that there can be cyclic pelvic pain associated with the menstrual cycle, but there can be noncyclic pain also, pain that is not related to the period, or there can be a presentation of pain with intercourse, or there can be no symptoms at all of endometriosis,” she said.

The symptom range extends further still. Appelbaum noted that endometriosis “can be as broad as having some genitourinary symptoms like frequency of urination, dyschezia, which is pain with defecation, and sometimes it presents with infertility.”

When pain warrants a deeper dive

Appelbaum highlighted the stigma surrounding painful periods, which can lead patients and families to accept debilitating symptoms as normal.

“A lot of girls and their parents accept the fact that pain with periods is part of being a woman and part of being postmenarchal, that the cyclic pain associated with the menstrual cycle is something that we have to live with and endure,” she said, adding that clinicians can conflate primary dysmenorrhea with secondary dysmenorrhea that signals an underlying cause requiring treatment.

She offered a functional threshold for escalating evaluation.

“If a girl is not functioning well in her regular daily activities, she is either missing school, missing work, or school-related activities, her family functions, or social events because of her pain associated with her menstrual cycle, that requires a deeper dive, and not to minimize those symptoms and not to normalize them because maybe they are not normal,” Appelbaum said.