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In a healthy female reproductive cycle, endometrial tissue, which lines the uterine walls, builds throughout the month to create a nurturing environment for a fertilized egg to implant. If there is no fertilized egg, the woman menstruates, discarding that excess blood and endometrial tissue, which is what happens during a typical period.
Imagine what happens when a tissue similar to endometrial tissue is present outside the uterus. It could be attached to either the ovaries, fallopian tubes, bladder or pelvic lining. But every month it behaves like it’s inside the uterus, building up and trying to shed. But instead of exiting the body, it has nowhere to go.
That’s when endometriosis develops, which consists of irritated tissues, the formation of cysts, scarring and adhesions. Sometimes bands of fibrous tissue form, causing the organs and pelvic tissues to stick together. To exacerbate the issue, endometriosis is not easy to diagnose, partly because the symptoms often mimic menstrual pain. Other symptoms are nonspecific, meaning they could be attributed to a number of other problems.
Endometriosis is quite common, affecting more than 11% of women in the U.S. between ages 15 and 44 and an estimated 7% of women ages 18 to 49 in Canada. In addition to being painful, those with endometriosis may have difficulty becoming pregnant.
The other difficulty with diagnosing endometriosis is that there is not a definitive way to diagnose it without surgery. Imaging tests can provide some clues but they’re not usually the ultimate answer leaving many to ask, why doesn’t endometriosis show on imaging? This may be explained when taking a close look at some of the imaging tests traditionally ordered when a patient presents with endometriosis symptoms.
How is endometriosis diagnosed? It’s helpful to understand some of the most common symptoms first.
Endometriosis does not usually develop until several years after a woman begins menstruating. Women who have never given birth are more prone to it, as are those who start their period at a younger age than what is typical. It’s also more common in women who go through menopause at an older age and those whose menstrual cycles are shorter than the typical 28 days or who bleed longer than 7 days during a cycle. Women with a family history of endometriosis are more at risk, as are those with a low body mass index.
How is endometriosis diagnosed? A doctor may use a number of methods to assess a patient for potential and suspected endometriosis.
Pelvic exam: The doctor may do a pelvic exam to feel for cysts or potential scars that might be caused by the tissue. The method only provides clues if the doctor feels a cyst, which is not always present with endometriosis.
Pelvic Ultrasound: This imaging technique uses high-frequency sound waves to create images of the pelvic area to look for cysts, which are also known as endometriomas. The ultrasound transducer might be pressed against the abdomen, or it could be inserted as a wand into the vagina, providing closer access to the pelvic organs.
Ultrasounds are easy, accessible and noninvasive (or minimally invasive). It’s usually the first imaging technique used when a patient presents with endometriosis symptoms. You can expect an ultrasound to take approximately 30 minutes.
Back to the earlier question of why doesn’t endometriosis show on imaging: sometimes it does. If cysts or clumps of tissues on an organ show up, that could be enough to diagnose. But ultrasounds can’t detect cysts if they’re too small or on the surface. Additionally, it’s not always possible to differentiate endometrial tissue from the other tissue.
MRI: Magnetic resonance imaging is another imaging technique that may be helpful in detecting endometriomas. It uses a magnetic field and radio waves to create detailed images of the pelvic area, allowing the radiologist to look for the cysts. Endometriosis imaging with MRI may detect smaller areas of endometriosis, and those located deeper in the body than ultrasound.
MRI is often used in conjunction with pelvic ultrasound. It can help doctors detect smaller cysts and tissues. It provides a more detailed view of the uterus, ovaries, bladder, bowel and surrounding areas.
Patients are advised to halt eating and drinking four to six hours prior to an MRI exam. Right before the exam, a patient is administered an intravenous contrast (gadolinium). Your doctor may also order a vaginal or rectal gel to be inserted before the MRI to allow for better insertion. The MRI exam takes approximately 45-60 minutes and patients may go home once it’s complete.
Laparoscopy: Surgery is the most definitive way to determine if a woman has endometriosis. That’s because the surgeon can look for the tissue’s presence and biopsy it. In some cases, the surgeon may be able to remove the endometrial cells and scar tissue with a minimally invasive procedure known as laparoscopy. The surgeon feeds a thin tube with a light into the pelvic area, allowing them to see inside the abdomen with only a small incision. The procedure can take as little as 1.5 hours for mild cases and up to 4 hours for the most severe endometriosis.
There are several approaches to treating endometriosis, most of them are varying combinations of medications or surgery.
Medication options range from over-the-counter pain medication, like ibuprofen or other nonsteroidal anti-inflammatory drugs (NSAIDs). Hormone therapy, including those used for birth control, is sometimes recommended to reduce tissue growth and decrease new tissue adhering in the pelvis. Other hormonal therapies are prescribed to stop menstrual periods, which may improve the symptoms as well.
As mentioned previously, laparoscopy may be the best option. In more severe, yet rare, cases, a laparotomy may be necessary. This involves a larger incision in the abdomen in order to remove more scar tissue from multiple reproductive organs. Today, laparotomies are rarely performed and laparoscopy is usually sufficient in treating endometriosis.
If you do go for imaging to help detect endometriosis, you can conveniently share your scans with other providers, while maintaining centralized access to those records yourself. PocketHealth is a patient-centered image-sharing platform that gives patients fast access to both imaging and reports and the ability to share their medical imaging records from anywhere and anytime. This is especially helpful when seeing multiple doctors about a medical issue.
Endometriosis may involve consultations with your family doctor along with several specialists such as a gynecologist, endocrinologist, surgeon or even a fertility specialist. Having rapid access to imaging, along with the ability to electronically share records from any device can have a fundamental impact on your care.
If you are interested in more information about endometriosis, visit the Endometriosis Network Canada website or the U.S. Department of Health & Human Services’ Office on Women’s Health.