Japanese Translation

Diagnosis
(supporting documentation)

B

For a definitive diagnosis of endometriosis visual inspection of the pelvis at laparoscopy is the gold standard investigation, unless disease is visable in the vagina or elsewhere.

Evidence Level 3

There is insufficient evidence to justify timing the laparoscopy at a specific time in the menstrual cycle, but it should not be performed during or within three months of hormonal treatment so as to avoid under-diagnosis (Evers, 1987).

Histology

GPP

Positive histology confirms the diagnosis of endometriosis; negative histology does not exclude it. Whether histology should be obtained if peritoneal disease alone is present is controversial: visual inspection is usually adequate but histological confirmation of at least one lesion is ideal. In cases of ovarian endometrioma (> 4 cms in diameter), and in deeply infiltrating disease, histology should be obtained to identify endometriosis and to exclude rare instances of malignancy.

GPP	If the patient wants pain symptoms suggestive of endometriosis to be treated without a definitive diagnosis, then a therapeutic trial of a hormonal drug to reduce menstrual flow is appropriate (see Empirical Treatment section).

GPP

The management of severe/deeply infiltrating endometriosis is complex. Therefore, if disease of such severity is suspected or diagnosed, referral to a centre with the necessary expertise to offer all available treatments in a multi-disciplinary context, including advanced laparoscopic surgery and laparotomy, is strongly recommended.

Microscopically, endometriotic implants consist of endometrial glands and stoma with or without haemosiderin-laden macrophages. The value of histological confirmation of the laparoscopic view for the diagnosis of endometriosis has to be further evaluated. In some studies the confirmation rate from biopsies of endometriotic lesions with a "typical" appearance has been low (Moen et al., 1992; Walter et al., 2001). This might occur because edometriotic lesions are often either extremely small or consist mainly of fibrotic tissue; because biopsies taken with forceps may miss microscopic endometriotic glands and sparse stroma hidden in fibrosis or other surrounding tissues. Thus, a biopsy might be negative because of the surgeon's limited experience, the size of the biopsy, the experience of the pathologist, the quality of the histological sample.

Concise