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Although endometriosis is a common gynaecological condition, it continues to present significant challenges for both patients and clinicians. It is striking that, in some cases, it can take up to 10 years from the onset of symptoms to the correct diagnosis of endometriosis. During this delay, patients often consult multiple specialists – including gastroenterologists, urologists, pain management physicians, psychiatrists, and even several gynaecologists. Various tests have been carried out, but no answer has been found. Interestingly, it is often the patients themselves who first raise the possibility that endometriosis may be the cause of their symptoms. This may explain why endometriosis is one of the clearest examples of diagnostic failure, leading to delayed and often inadequate care for patients worldwide.
Endometriosis is a benign gynaecological condition estimated to affect at least 10% of women. The main symptoms are pain and infertility. These symptoms can occur together or separately. One of the key characteristics of endometriosis is that the severity of symptoms does not necessarily correlate with the extent of the disease. The “stage” or “grade” is not always emphasised, as misinterpretation can lead patients to compare endometriosis with malignant conditions, which it is not. For example, a patient with extensive endometriosis affecting the ovaries, bowel, or bladder may only experience minimal symptoms, whereas another patient with a single, deep lesion may suffer from severe pain, sometimes radiating to the leg or back. It should be mentioned straight away that endometriosis occurs in up to 50% or more of infertility patients. Unfortunately, these patients – without the classic endometriotic cyst easily recognised by most gynaecologists – are often left undiagnosed, even though their symptoms may include not only infertility but also painful menstruation, painful intercourse, and other symptoms that are frequently normalised or overlooked. It is important to note that endometriosis-related pain can vary widely and may involve bowel or bladder function. As a result, patients do not always consult a gynaecologist first but often seek help from other specialists.
The good news is that diagnosing endometriosis does not always take years; however, delayed cases are not uncommon, and the diagnostic process often falls short of patients’ expectations.
For example, a patient who was diagnosed with endometriosis more than 15 years ago was recently consulted in our clinic. Unfortunately, even this fact did not help the patient receive an adequate assessment of endometriosis, although several laparoscopic operations were performed. Remarkably, after more than 15 years of symptoms and a confirmed diagnosis of endometriosis with ineffective hormonal treatment, the condition was only recently identified with ultrasound – despite evidence in previous examinations suggesting that the lesions had already been visualised but not recognised. Unfortunately, many such cases exist in which even large bowel lesions go undetected, and endometriosis is only considered once an endometriotic cyst is identified – despite the patient having had symptoms for many years.
A gynaecologist in Latvia is a direct access specialist, which means that any patient, without a referral from a general practitioner, can have a consultation with a gynaecologist. Most of these specialists are also certified in gynaecological ultrasound and offer it to their patients if necessary. Logically, a patient presenting with endometriosis-specific symptoms should receive a diagnosis after just one visit. Unfortunately, as in many other countries, this is not the case in Latvia.
The definitive diagnosis of endometriosis can only be made through the histological examination of tissue samples obtained during surgery. However, this is not always necessary, especially if the patient has no symptoms and the diagnostic finding is typical for endometriosis.
Gynaecological ultrasound is currently the most effective non-invasive diagnostic method for endometriosis, but patients do not always perceive it as the most accurate or reliable tool. This disbelief often emerges when deep endometriotic lesions are detected in the bowel or other pelvic structures during an examination, surprising patients who have undergone multiple ultrasounds each year without such findings. This begs the question – why? The simple answer is specialisation in the diagnosis and treatment of endometriosis.
Gynaecological ultrasound has many advantages over other diagnostic methods, such as magnetic resonance imaging (MRI), which is often regarded by patients and even many clinicians as more accurate, and sometimes referred to as a confirmatory test. However, long-term research and data analyses have demonstrated that gynaecological ultrasound provides greater accuracy than other imaging methods in diagnosing pelvic endometriosis. It is also cheaper, quicker and easier to access. But, as with any type of test, the accuracy of the results depends very much on the clinician carrying out the test. In endometriosis, it is well established that nearly all gynaecologists performing ultrasound can accurately identify an ovarian endometriotic cyst (endometrioma). Recognition of this typical finding often “saves” the patient, as it finally leads to the correct diagnosis. Unfortunately, other forms of endometriosis – particularly deep lesions – are recognised far less frequently, including those in the bowel, which may sometimes be the only manifestation of the disease. And even when an endometrioma is found, we need to look further, as it is rare to find a cyst without the presence of other lesions.
Targeted examination is essential for diagnosing endometriosis – not only of the uterus and ovaries but also of all pelvic structures, even when the ovaries appear to be completely normal. The diagnostic process can be time-consuming and may appear complex at first, but with increasing experience and daily exposure to endometriosis cases, it is becoming faster and more accurate.
When deep endometriotic lesions are identified on gynaecological ultrasound, the question often arises of whether magnetic resonance imaging (MRI) is required for confirmation. No – when endometriosis is clearly identified, for example, in the bowel, additional tests are usually unnecessary.
Despite the high accuracy of gynaecological ultrasound, it is important to recognise that it is neither 100% sensitive nor specific and cannot detect all forms of endometriosis. MRI serves as an additional diagnostic tool for patients suspected of having endometriosis in areas that are difficult to assess with ultrasound, such as the caecum, bowel segments above the pelvis, or the diaphragm.
It is also important to highlight diagnostic laparoscopy, which is sometimes overlooked and not offered in cases where the diagnosis remains uncertain. Diagnostic laparoscopy is recommended for patients with severe symptoms when neither ultrasound nor MRI confirms the presence of endometriosis. In such cases, surgery is planned on a “see and treat” basis, meaning that if endometriosis is identified, it is surgically treated during the same procedure.
Other tests, such as a colonoscopy or computed tomography (CT), should be reserved for differential diagnosis, for example, when malignancy is suspected. These are not the methods of choice for diagnosing endometriosis. For example, endometriosis in the bowel wall is unlikely to be visible during a colonoscopy because it is located in the muscle layer and rarely reaches the mucosa.
Gynaecological ultrasound is currently one of the best diagnostic methods for endometriosis, especially in the hands of a knowledgeable specialist. This approach helps determine the most appropriate treatment strategy and allows the patient to receive a detailed explanation regarding the changes present in the affected organs. Gynaecological ultrasound can not only detect ovarian cysts but also show bowel, bladder and other pelvic lesions.
We encourage you to choose doctors who specialise in the diagnosis and treatment of endometriosis.
Important to remember!
