Endometriosis is a process in which a benign growth of tissue occurs outside the uterine cavity, similar in morphological and functional properties to the endometrium. Difficulties in managing patients with endometriosis are associated with a highly variable clinical picture, and the severity of the course of the disease, tactics depend on the age of patients, the stage of the disease, the nature of symptoms, reproductive tasks, as well as on the risks, side effects and economic profitability of treatment. In some cases, endometriosis is a chronic recurrent disease requiring constant attention and treatment. The analysis of the patient’s complaints and the traditional gynecological examination only suggest the presence of endometriosis. Therefore, the most correct and frequently used screening method is ultrasound, which allows doctors to detect specific patterns of the disease.
Frequent Complaint
Endometriosis is a disease in which tissue similar to the endometrium (the inner layer of the uterus) grows outside the uterus, causing pain or infertility. Worldwide, endometriosis affects approximately 10% (190 million or more) of women and girls of reproductive age (Parazzini et al., 2020). Due to the variety of symptoms of endometriosis, it is not easy for health care workers to diagnose this disease, and many people suffering from it do not know much about it (Chapron et al., 2019). Therefore, it sometimes takes quite a long time from the onset of symptoms to the diagnosis. Approximately 30% of women of reproductive age complain of symptoms characteristic of this disease (Parazzini et al., 2020). The peak of endometriosis occurs in the age group from 30 to 50 years. Among all gynecological pathologies, endometriosis ranks third, second only to fibromyomas and various inflammatory processes.
In healthy women, endometrial cells should not survive in unusual places due to their programmed death and the inhibitory effect of the peritoneum on their development. However, in patients with an established diagnosis of endometriosis, there is a decrease in the processes of spontaneous cell death in the foci of endometriosis (Chapron et al., 2019). Complaints of dyspareunia (pain during sexual activity) are presented by 26-70% of patients with genital endometriosis, and infertility (both primary and secondary) is recorded in 46-50% of cases (Parazzini et al., 2020). Pain symptoms may also depend on the localization of lesions.
Screening Tool
Currently, an echography is mainly used to diagnose internal endometriosis. If internal endometriosis is suspected, an ultrasound test should be performed in the second phase of the menstrual cycle, preferably a few days before the start of menstruation (van den Bosch & van Schoubroeck, 2018). At the same time, the most significant attention, especially for the diagnosis of the initial manifestations of endometriosis, should be paid to the condition of the basal layer of the endometrium (Scioscia et al., 2020). In order to detect internal endometriosis, only vaginal echography should be used and performed before and after menstruation.
The key to the successful treatment of many diseases is early diagnosis, but in the case of endometriosis, detecting the pathological process in the early stages is extremely difficult. This is due to the versatility of the clinical picture and the lack of pathognomonic signs and standards of methods for evaluating examination data (van den Bosch & van Schoubroeck, 2018). Due to the aseptic inflammation of the peritoneum accompanying the adhesive process in endometriosis, an increase in the volume of peritoneal fluid is detected during an echographic examination (Scioscia et al., 2020). During the ultrasound examination, the patient lies on his back. The doctor may require that he has an empty or full bladder, depending on which part of the pelvis they will check or on the ultrasound scanning method.
Supporting Rationales
The implementation of this screening tool allows medical professionals to identify the following most characteristic signs of the prevalence of endometriosis (van den Bosch & van Schoubroeck, 2018):
- formation of small (about 1 mm in diameter) anechoic tubular structures extending from the endometrium towards the myometrium;
- the appearance of small hypo- and anechoic inclusions of round or oval shape with a diameter of about 1-2 mm in the basal layer of the endometrium;
- uneven thickness of the basal layer of the endometrium;
- serration or indentation of the basal layer of the endometrium;
- detection of local endometrial defects;
- the appearance of separate areas of increased echogenicity up to 3 mm thick in the myometrium directly adjacent to the uterine cavity.
Factors
The presented data indicate that echography is currently the most informative method of diagnosing adenomyosis, despite specific difficulties and well-known subjectivity in the interpretation of echograms. The most significant difficulties arise when endometriosis adenomyosis is combined with multiple interstitially located myomatous nodes (Scioscia et al., 2020). In such cases, it is not always possible to establish or exclude the pathology in question with an echography.
Validity
The most optimal and accessible are ultrasound endocavital research methods that visualize signs of the presence of endometrioid ovarian cysts: increased echogenicity, deformations of ovarian contours, echopositive homogeneous inclusions with clear contours, double contours of formations. Due to the aseptic inflammation of the peritoneum accompanying the adhesive process in endometriosis, an increase in the volume of peritoneal fluid is detected during an echographic examination.
Sensitivity
The helpful signal/noise ratio determines the sensitivity of the ultrasonic system. Thus, the scanner’s sensitivity will be determined by how it will recognize proper acoustic signals among much interference. One ultrasound of the pelvis with endometriosis is often not enough (Leonardi & Condous, 2018). However, this type of examination can also be useful if it is conducted in a suitable period of time. To diagnose other diseases, it is recommended to do an ultrasound examination in the first week after the end of menstruation (from the fifth to the seventh day), when the tissues of the intrauterine layer are the thinnest.
Specificity
This method is painless; it is not traumatic and is harmless to patients. The technique allows the doctor to identify all changes in the structure of the mucous and muscular layer of the uterus. Endometriosis is diagnosed by ultrasound using a vaginal sensor. The procedure is performed on the 25th day of the monthly cycle when structural changes are pronounced (Leonardi & Condous, 2018). If the disease is already in the body, then the ultrasound monitor will clearly show the increased size of the uterus characteristic of endometriosis and the different density of the muscle layer in its areas. Furthermore, the gynecologist will see the absence or presence of a capsule in the inner layer.
Potential Ethical Issues
It should be noted that gynecological ultrasound is a rather delicate procedure. Therefore, it is necessary to observe several patient rights regarding the choice of treatment method and the degree of intervention of a medical professional. Carrying out this procedure involves examining the inner layer of the walls of the uterus. Thus, patients should be appropriately informed and prepared for what they will face. In addition, it should be mentioned that the patient has the right to decide which examination is acceptable and necessary for herself (Martire et al., 2020). Before the examination, the woman is informed about what and how the doctor will do, and at the end of the procedure, she receives a conclusion with a transcript of the ultrasound results and can ask the specialist all the essential questions.
For ultrasound, the patient sits on the couch and exposes her stomach. The doctor applies a special gel to the sensor, and the skin of the patient’s abdomen moves the sensor with slight pressure on the skin (Leonardi & Condous, 2018). In this case, the medical specialist must comply with the requirements associated with a certain measure of the permissibility of interference in the patient’s personal space. In addition, it should be understood that the ultrasound method should be associated with a certain allowable number of times. Therefore, it is necessary to provide the patient with a complete picture of how often he will have to attend this procedure.
Conclusion
Summing up the above, it is worth noting that genital endometriosis today is a reasonably common disease detected mainly in women of fertile age. It is essential to emphasize the need for early diagnosis of endometrioid disease, the study of symptoms and possible causes, and the search for effective treatment methods. This pathological process leads to severe complications, including pain syndrome, the development of infertility, and depression of the psycho-emotional state, which significantly worsens the quality of life of women of different ages. Endometriosis is a common and painful condition that occurs when the tissue of the uterine mucosa grows beyond the uterus. Ultrasound is useful for diagnosing endometriosis and assessing the severity of the condition. However, its accuracy may depend on the person performing the scan.
References
Chapron, C., Marcellin, L., Borghese, B., & Santulli, P. (2019). Rethinking mechanisms, diagnosis and management of endometriosis. Nature Reviews Endocrinology, 15(11), 666–682.
Leonardi, M., & Condous, G. (2018). How to perform an ultrasound to diagnose endometriosis. Australasian Journal of Ultrasound in Medicine, 21(2), 61–69.
Martire, F. G., Lazzeri, L., Conway, F., Siciliano, T., Pietropolli, A., Piccione, E., Solima, E., Centini, G., Zupi, E., & Exacoustos, C. (2020). Adolescence and endometriosis: Symptoms, ultrasound signs and early diagnosis.Fertility and Sterility, 114(5), 1049–1057.
Parazzini, F., Roncella, E., Cipriani, S., Trojano, G., Barbera, V., Herranz, B., & Colli, E. (2020). The frequency of endometriosis in the general and selected populations: A systematic review. Journal of Endometriosis and Pelvic Pain Disorders, 12(3–4), 176–189.
Scioscia, M., Virgilio, B. A., Laganà , A. S., Bernardini, T., Fattizzi, N., Neri, M., & Guerriero, S. (2020). Differential diagnosis of endometriosis by ultrasound: A rising challenge.Diagnostics, 10(10), 848–862.
van den Bosch, T., & van Schoubroeck, D. (2018). Ultrasound diagnosis of endometriosis and adenomyosis: State of the art.Best Practice and Research Clinical Obstetrics and Gynaecology, 51, 16–24.