Endometriosis awareness (Part 2): Diagnosis and treatment

Endometriosis is a complex medical condition, affecting 1.5 million women in the UK, that can manifest with diverse clinical presentations.

Mr George Goumalatsos is a renowned consultant gynaecologist and obstetrician in Basingstoke. In the second of two articles on endometriosis, Mr Goumalatsos offers an expert insight into the diagnostic process and the treatment options available for endometriosis.

How is endometriosis diagnosed?

The gold standard for diagnosing endometriosis is through a laparoscopy and a biopsy of the suspicious areas. However, before considering surgery, the process of examination begins with a thorough medical history review. We focus on understanding the patient’s symptoms, their duration, their aggravating factors, and their relation to the menstrual cycle.

If there is suspicion of endometriosis, the diagnostic tests may include:

• Pelvic examination: Typically revealing tenderness in the womb or ovaries, this examination can identify ovarian cysts and scar tissue behind the womb.
• Ultrasound: The transvaginal ultrasound scan is the most accurate method for assessing the womb and ovaries. Using a thin probe inserted into the vagina and ultrasound waves, it generates images of the womb and ovaries. Mild superficial endometriosis may not be visible, but endometriomas (endometriotic cysts in the ovaries) will be identified.
• MRI: MRI scans utilise a magnetic field to produce detailed internal images of the body. Particularly useful before surgery to address severe endometriosis, MRI scans help to pinpoint the exact location of endometriotic nodules.
• Laparoscopy: Laparoscopy, or keyhole surgery, involves up to four small abdominal incisions. It also utilises a telescopic microscope (laparoscope), which is inserted through the belly button to aid in diagnosis or treatment. Laparoscopy, in addition to the excision of suspected endometriotic lesions, is considered the definitive method for diagnosing endometriosis.

How is endometriosis treated?

Treatment options for endometriosis involve either medications or surgery. The choice of treatment depends on various factors and considerations, such as prior treatments and fertility preferences.

Medical treatment options include:

• Painkillers: A combination of paracetamol and NSAIDs (nonsteroidal anti-inflammatory drugs) like ibuprofen, diclofenac, or naproxen often provides relief from menstrual pain.
• Hormonal contraceptives: The oral contraceptive pill or the vaginal ring may regulate the hormones involved in endometriosis. Taking the pill continuously for three months, rather than monthly, may reduce the frequency and severity of painful periods. Progesterone-only contraceptives, such as the Mirena coil, implant, injection or mini-pill, can halt periods and temporarily alleviate endometriosis symptoms.
• Gonadotrophin-releasing agonists (GnRH): These injections induce temporary menopause and significantly improve endometriosis-related pain. However, GnRH come with side effects such as hot flushes and night sweats. If prescribed for over six months, they may lead to osteoporosis. To mitigate side effects, an add-back hormone replacement therapy is typically recommended as well.

If medical management proves ineffective, surgery becomes the next option, serving both diagnostic and therapeutic purposes.

Common surgical procedures include:

• Laparoscopic excision of endometriosis: Keyhole surgery to remove lesions and/or endometriomas can alleviate pain and increase the chances of successful pregnancy, even in severe cases of endometriosis.
• Hysterectomy with removal of the ovaries: When other treatments fail and family planning is complete, this is a final option. A hysterectomy with removal of the ovaries stops oestrogen stimulation of endometriosis. This will induce the menopause, and thus hormone replacement therapy (HRT) is often recommended to enhance quality of life.

To schedule an appointment with Mr George Goumalatsos, head on over to his Top Doctors profile today.