Editing Endometriosis (section)

==Diagnosis==
A health history and a physical examination can lead the health care practitioner to suspect endometriosis. There is a clear benefit for performing a [[transvaginal ultrasound]] (TVUS) as a first step of testing for endometriosis.<ref name="Van den Bosch Van Schoubroeck 2018 pp. 16–24"/>

Definitive diagnosis is based on the [[Morphology (biology)|morphology]] (form and structure) of the pelvic region, determined by observation (surgical or non-invasive imaging), and classified into four different stages of endometriosis. The American Society of Reproductive Medicine's scale, revised in 1996, gives higher scores to deep, thick lesions or intrusions on the ovaries and dense, enveloping adhesions on the ovaries or fallopian tubes.<ref name="pmid9130884"/> Additionally, [[histology|histological]] studies, when performed, should show specific findings.

For many patients, there are significant delays in diagnosis. Studies show an average delay of 11.7 years in the United States. Patients in the UK have an average delay of 8 years and in Norway of 6.7 years.<ref name="ReferenceA">{{cite journal | vauthors = Pugsley Z, Ballard K | title = Management of endometriosis in general practice: the pathway to diagnosis | journal = The British Journal of General Practice | volume = 57 | issue = 539 | pages = 470–6 | date = June 2007 | pmid = 17550672 | pmc = 2078174 }}</ref> A third of women had consulted their GP six or more times before being diagnosed.<ref name="ReferenceA"/>

The most common sites of endometriosis are the ovaries, followed by the Douglas pouch, the posterior leaves of the broad ligaments, and the sacrouterine ligaments.<ref name="ovarianendo"/>

As for deep infiltrating endometriosis, TVUS, [[TRUS]] and MRI are the techniques of choice for non-invasive diagnosis with a high sensitivity and specificity.<ref name="Zhang He Shen 2020 p.">{{cite journal | vauthors = Zhang X, He T, Shen W | title = Comparison of physical examination, ultrasound techniques and magnetic resonance imaging for the diagnosis of deep infiltrating endometriosis: A systematic review and meta-analysis of diagnostic accuracy studies | journal = Experimental and Therapeutic Medicine | volume = 20 | issue = 4 | pages = 3208–3220 | date = October 2020 | pmid = 32855690 | pmc = 7444323 | doi = 10.3892/etm.2020.9043 | publisher = Spandidos Publications }}</ref>

===Laparoscopy===
[[File:Endometrioma.jpg|thumb|[[Transvaginal ultrasonography]] showing a 67 x 40 mm [[endometrioma]] as distinguished from other types of [[ovarian cyst]]s by a somewhat grainy and not completely [[anechoic]] content]]
Laparoscopy, a surgical procedure where a camera is used to look inside the abdominal cavity, is the only way to accurately diagnose the extent and severity of pelvic/abdominal endometriosis.<ref name="Imaging">{{cite journal | vauthors = Nisenblat V, Bossuyt PM, Farquhar C, Johnson N, Hull ML | title = Imaging modalities for the non-invasive diagnosis of endometriosis | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | pages = CD009591 | date = February 2016 | issue = 2 | pmid = 26919512 | doi = 10.1002/14651858.cd009591.pub2 | pmc = 7100540 }}</ref> Laparoscopy is not an applicable test for extrapelvic sites such as umbilicus, hernia sacs, abdominal wall, lung, or kidneys.<ref name="Imaging"/>

Reviews in 2019 and 2020 concluded that 1) with advances in imaging, endometriosis diagnosis should no longer be considered synonymous with immediate laparoscopy for diagnosis, and 2) endometriosis should be classified as a syndrome that requires confirmation of visible lesions seen at laparoscopy in addition to characteristic symptoms.<ref>{{cite journal |vauthors=Chapron C, Marcellin L, Borghese B, Santulli P |title=Rethinking mechanisms, diagnosis and management of endometriosis |journal=Nat Rev Endocrinol |volume=15 |issue=11 |pages=666–682 |date=November 2019 |pmid=31488888 |doi=10.1038/s41574-019-0245-z |s2cid=201838966 }}</ref><ref>{{cite web |url=https://blogs.bmj.com/bmj/2020/08/11/reclassifying-endometriosis-as-a-syndrome-would-benefit-patient-care/ |title=Reclassifying endometriosis as a syndrome would benefit patient care - The BMJ |date=11 August 2020 |access-date=17 August 2020 |archive-date=13 August 2020 |archive-url=https://web.archive.org/web/20200813021150/https://blogs.bmj.com/bmj/2020/08/11/reclassifying-endometriosis-as-a-syndrome-would-benefit-patient-care/ |url-status=live }}</ref>

Laparoscopy permits lesion visualization unless the lesion is visible externally (e.g., an endometriotic nodule in the vagina) or is extra-abdominal.<ref name="Imaging" /> If the growths (lesions) are not visible, a biopsy must be taken to determine the diagnosis.<ref name="John2013"/> Surgery for diagnoses also allows for surgical treatment of endometriosis at the same time.

During a laparoscopic procedure, lesions can appear dark blue, powder-burn black, red, white, yellow, brown, or non-pigmented. Lesions vary in size.<ref name="pmid20436318"/> Some within the pelvic walls may not be visible, as the normal-appearing peritoneum of infertile women reveals endometriosis on biopsy in 6–13% of cases.<ref>{{cite journal | vauthors = Nisolle M, Paindaveine B, Bourdon A, Berlière M, Casanas-Roux F, Donnez J | title = Histologic study of peritoneal endometriosis in infertile women | journal = Fertility and Sterility | volume = 53 | issue = 6 | pages = 984–8 | date = June 1990 | pmid = 2351237 | doi = 10.1016/s0015-0282(16)53571-7 | doi-access = free | title-link = doi }}</ref> Early endometriosis typically occurs on the surfaces of organs in the pelvic and intra-abdominal areas.<ref name="pmid20436318">{{cite journal |vauthors=Hsu AL, Khachikyan I, Stratton P |title=Invasive and noninvasive methods for the diagnosis of endometriosis |journal=Clin Obstet Gynecol |volume=53 |issue=2 |pages=413–9 |date=June 2010 |pmid=20436318 |pmc=2880548 |doi=10.1097/GRF.0b013e3181db7ce8 }}</ref> Health care providers may call areas of endometriosis by different names, such as implants, lesions, or nodules. Larger lesions may be seen within the ovaries as [[endometrioma]]s or "chocolate cysts"; "chocolate" because they contain a thick brownish fluid, mostly old blood.<ref name="pmid20436318"/>

Frequently, during diagnostic laparoscopy, no lesions are found in individuals with chronic pelvic pain, a symptom common to other disorders including [[adenomyosis]], pelvic adhesions, pelvic inflammatory disease, [[congenital anomalies]] of the [[reproductive tract]], and ovarian or tubal masses.<ref name="committee">{{cite journal |title=Treatment of pelvic pain associated with endometriosis: a committee opinion |journal=Fertility and Sterility |volume=101 |issue=4 |pages=927–35 |date=April 2014 |pmid=24630080 |doi=10.1016/j.fertnstert.2014.02.012 |author1=Practice Committee of the American Society for Reproductive Medicine |doi-access=free |title-link=doi}}</ref>

=== Ultrasound ===
Vaginal ultrasound can be used to diagnosis endometriosis, or for localizing endometrioma before surgery.<ref name=":0">{{cite web|url=https://www.sbu.se/en/publications/sbu-assesses/endometriosis--diagnosis-treatment-and-patient-experiences/|title=Endometriosis – Diagnosis, treatment and patient experiences|date=4 May 2018|publisher=[[Swedish Agency for Health Technology Assessment and Assessment of Social Services]] (SBU)|access-date=13 June 2018|archive-date=19 January 2021|archive-url=https://web.archive.org/web/20210119024015/https://www.sbu.se/en/publications/sbu-assesses/endometriosis--diagnosis-treatment-and-patient-experiences/|url-status=live}}</ref> This can be used to identify the spread of disease in individuals with well-established clinical suspicion of endometriosis.<ref name=":0" /> Vaginal ultrasound is inexpensive, easily accessible, has no contraindications and requires no preparation.<ref name=":0" /> By extending the ultrasound assessment into the posterior and anterior pelvic compartments a sonographer can evaluate structural mobility and look for deep infiltrating endometriotic nodules.<ref name=":2">{{cite journal |vauthors=Fang J, Piessens S |title=A step-by-step guide to sonographic evaluation of deep infiltrating endometriosis |journal=Sonography |date=June 2018 |volume=5 |issue=2 |pages=67–75 |doi=10.1002/sono.12149 |doi-access=free |title-link=doi}}</ref> Better sonographic detection of deep infiltrating endometriosis could reduce the number of diagnostic laparoscopies, as well as guide disease management and enhance patient quality of life.<ref name=":2" />

=== Magnetic resonance imaging ===
MRI is another means of detecting lesions in a non-invasive manner.<ref name="Imaging"/> MRI is not widely used due to its cost and limited availability, although it can be used to detect the most common form of endometriosis (endometrioma) with sufficient accuracy.<ref name="Imaging"/> A 2020 article recommended administering an anti-spasmodic agent (i.e., [[hyoscine butylbromide]]) and a big glass of water (if the bladder is empty) and scanning in the supine position with an abdominal strap for better image quality.<ref name=deependomri>{{cite journal |vauthors=Wild M, Pandhi S, Rendle J, Swift I, Ofuasia E |title=MRI for the diagnosis and staging of deeply infiltrating endometriosis: a national survey of BSGE accredited endometriosis centres and review of the literature |journal=Br J Radiol |volume=93 |issue=1114 |page=20200690 |date=October 2020 |pmid=32706984 |doi=10.1259/bjr.20200690 |pmc=7548358 }}</ref> It also recommended using [[Endorectal coil magnetic resonance imaging|pelvic-phased array coils]] and T1 (spin-lattice) weighted scanning, with and without suppression of fat for endometriomas, and sagittal, axial and oblique 2D T2 (spin-spin) weighting for deep infiltrating endometriosis.<ref name=deependomri/> {{See also|MRI sequence}}

===Stages of disease===
By surgical observation, endometriosis can be classified as stage I–IV by the 1996 scale of the [[American Society of Reproductive Medicine]] (ASRM).<ref name="pmid9130884">{{cite journal | title = Revised American Society for Reproductive Medicine classification of endometriosis: 1996 | journal = Fertility and Sterility | volume = 67 | issue = 5 | pages = 817–21 | date = May 1997 | pmid = 9130884 | doi = 10.1016/S0015-0282(97)81391-X | last1 = American Society For Reproductive | doi-access = free | title-link = doi }}</ref> The scale uses a point system that assesses lesions and adhesions in the pelvic organs. It is important to note that staging assesses physical disease only, not the level of pain or infertility.<ref>{{cite journal | vauthors = Vercellini P, Fedele L, Aimi G, Pietropaolo G, Consonni D, Crosignani PG | title = Association between endometriosis stage, lesion type, patient characteristics and severity of pelvic pain symptoms: a multivariate analysis of over 1000 patients | journal = Human Reproduction | volume = 22 | issue = 1 | pages = 266–71 | date = January 2007 | pmid = 16936305 | doi = 10.1093/humrep/del339 | doi-access = free | title-link = doi }}</ref> A person with Stage I endometriosis may have a little disease and severe pain, while a person with Stage IV endometriosis may have severe disease and no pain or vice versa. The various stages are summarized by:

Stage I (Minimal)
: Findings restricted to only superficial lesions and possibly a few filmy adhesions.
Stage II (Mild)
: In addition, some deep lesions are present in the [[Rectouterine pouch|cul-de-sac]].
Stage III (Moderate)
: As above, plus the presence of endometriomas on the ovary and more adhesions.
Stage IV (Severe)
: As above, plus large endometriomas and extensive adhesions. Implants and adhesions may be found beyond the uterus. Large ovarian cysts are common.

===Markers===
An area of research is the search for endometriosis [[biomarker|markers]].<ref name=May2010/>

In 2010, essentially all proposed biomarkers for endometriosis were of unclear medical use, although some appear to be promising.<ref name="May2010">{{cite journal | vauthors = May KE, Conduit-Hulbert SA, Villar J, Kirtley S, Kennedy SH, Becker CM | title = Peripheral biomarkers of endometriosis: a systematic review | journal = Human Reproduction Update | volume = 16 | issue = 6 | pages = 651–74 | year = 2010 | pmid = 20462942 | pmc = 2953938 | doi = 10.1093/humupd/dmq009 }}</ref> The one biomarker that has been in use over the last 20 years is [[CA-125]].<ref name=May2010/> A 2016 review found that this biomarker was present in those with symptoms of endometriosis; and, once ovarian cancer has been ruled out, a positive CA-125 may confirm the diagnosis.<ref name="Hir2016">{{cite journal | vauthors = Hirsch M, Duffy J, Davis CJ, Nieves Plana M, Khan KS | title = Diagnostic accuracy of cancer antigen 125 for&nbsp;endometriosis: a systematic review and meta-analysis | journal = BJOG | volume = 123 | issue = 11 | pages = 1761–8 | date = October 2016 | pmid = 27173590 | doi = 10.1111/1471-0528.14055 | s2cid = 22744182 | url = https://ora.ox.ac.uk/objects/uuid:d413105f-9fa2-43c8-9ee8-438c77725589 | archive-date = 26 April 2022 | access-date = 29 September 2020 | archive-url = https://web.archive.org/web/20220426034925/https://ora.ox.ac.uk/objects/uuid:d413105f-9fa2-43c8-9ee8-438c77725589 | url-status = live }}</ref> Its performance in ruling out endometriosis is low.<ref name=Hir2016/> CA-125 levels appear to fall during endometriosis treatment, but it has not shown a correlation with disease response.<ref name=May2010/>

Another review in 2011 identified several putative biomarkers upon biopsy, including findings of small sensory nerve fibers or defectively expressed [[Beta-3 integrin|β3 integrin]] subunit.<ref>{{cite journal | vauthors = May KE, Villar J, Kirtley S, Kennedy SH, Becker CM | title = Endometrial alterations in endometriosis: a systematic review of putative biomarkers | journal = Human Reproduction Update | volume = 17 | issue = 5 | pages = 637–53 | year = 2011 | pmid = 21672902 | doi = 10.1093/humupd/dmr013 | doi-access = free | title-link = doi }}</ref> It has been postulated a future diagnostic tool for endometriosis will consist of a panel of several specific and sensitive biomarkers, including both substance concentrations and genetic predisposition.<ref name=May2010/>

A 2016 review of endometrial biomarkers for diagnosing endometriosis was unable to draw conclusions due to the low quality of the evidence.<ref>{{cite journal | vauthors = Gupta D, Hull ML, Fraser I, Miller L, Bossuyt PM, Johnson N, Nisenblat V | title = Endometrial biomarkers for the non-invasive diagnosis of endometriosis | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | pages = CD012165 | date = April 2016 | issue = 4 | pmid = 27094925 | pmc = 6953323 | doi = 10.1002/14651858.CD012165 }}</ref>

MicroRNAs have the potential to be used in diagnostic and therapeutic decisions.<ref name=rna>{{cite journal |vauthors=Taghavipour M, Sadoughi F, Mirzaei H, Yousefi B, Moazzami B, Chaichian S, Mansournia MA, Asemi Z |title=Apoptotic functions of microRNAs in pathogenesis, diagnosis, and treatment of endometriosis |date=2020 |journal=Cell & Bioscience |pmid=32082539 |doi=10.1186/s13578-020-0381-0 |volume=10 |pmc=7014775 |page=12 |doi-access = free | title-link = doi }}</ref>

===Histopathology===
For a histopathological diagnosis, at least two of the following three criteria should be present:<ref>{{cite web | vauthors = Han L, Garcia R, Busca A, Parra-Herran C | date = November 2023 | veditors = Turashvili G, Skala SL | url = http://www.pathologyoutlines.com/topic/ovarynontumorendometriosis.html | title = Ovary - nontumor - Nonneoplastic cysts / other - Endometriosis | website = Pathology Outlines | access-date = 18 March 2020 | archive-date = 7 August 2020 | archive-url = https://web.archive.org/web/20200807014147/http://www.pathologyoutlines.com/topic/ovarynontumorendometriosis.html | url-status = live }}</ref>
* Endometrial type [[stroma (animal tissue)|stroma]]
* Endometrial [[epithelium]] with glands
* Evidence of chronic hemorrhage, mainly [[hemosiderin]] deposits

[[Immunohistochemistry]] is useful in diagnosing endometriosis as stromal cells have a peculiar surface antigen, CD10, thus allowing the pathologist go straight to a staining area and confirm the presence of stromal cells and sometimes glandular tissue is identified that was missed on routine [[H&E staining]].<ref>{{cite conference | vauthors = McMaster-Fay R, Osborn R, Chandraratnam E | title = The Clinical Utility Of CD10 Immunohistochemical Staining In The Diagnosis Of Endometriosis. | conference = 10th World Congress of Endometriosis | location = Melbourne, Australia. | url = http://www.rfay.com.au/docs/cd10poster.pdf |access-date=18 July 2013 |url-status=live |archive-url=https://web.archive.org/web/20130502131226/http://rfay.com.au/docs/cd10poster.pdf |archive-date=2 May 2013 }}</ref>

<gallery mode="packed" heights="175">
File:Endometriosis, abdominal wall.jpg|Endometriosis, abdominal wall
File:Endometriosis of the ovary.jpg|[[Micrograph]] showing endometriosis (right) and ovarian stroma (left)
File:Endometrioma1.jpg|[[Micrograph]] of the wall of an endometrioma. All features of endometriosis are present (endometrial [[gland]]s, endometrial [[stroma (animal tissue)|stroma]] and [[hemosiderin]]-laden [[macrophage]]s).
</gallery>

===Pain quantification===
The most common [[pain scale]] for quantification of endometriosis-related pain is the [[visual analogue scale]] (VAS); VAS and [[numerical rating scale]] (NRS) were the best adapted pain scales for pain measurement in endometriosis. For research purposes, and more detailed pain measurement in clinical practice, VAS or NRS for each type of typical pain related to endometriosis (dysmenorrhea, deep dyspareunia and non-menstrual chronic pelvic pain), combined with the [[clinical global impression]] (CGI) and a [[quality of life]] scale, are used.<ref name="BourdelAlves2014">{{cite journal | vauthors = Bourdel N, Alves J, Pickering G, Ramilo I, Roman H, Canis M | title = Systematic review of endometriosis pain assessment: how to choose a scale? | journal = Human Reproduction Update | volume = 21 | issue = 1 | pages = 136–52 | year = 2014 | pmid = 25180023 | doi = 10.1093/humupd/dmu046 | doi-access = free | title-link = doi }}</ref>