Japanese Translation

Investigations
(supporting documentation)

Ultrasound

A

Compared to laparoscopy, trans-vaginal ultrasound (TVS) has no value in diagnosing peritoneal endometriosis, but it is a useful tool both to make and to exclude the diagnosis of an ovarian endometrioma (Moore et al., 2002). TVS may have a role in the diagnosis of disease involving the bladder or rectum.

Systematic review of diagnostic tests

In a systematic review of the value of TVS as a diagnostic tool in endometriosis, only seven out of the 49 papers identified fulfilled the inclusion criteria (Moore et al., 2002). The positive likelihood ratios ranged from 7.6 - 29.8, and the negative likelihood ratios ranged from 0.12 - 0.4. Confidence intervals were wide. One paper addressed the use of conventional colour Doppler with ultrasound: the positive likelihood ratio was 1.2, with a negative likelihood ratio of 0.4 (Alcázar et al., 1997). One paper assessed the use of colour Doppler energy imaging, and showed a positive likelihood ratio of 33.5, and a negative likelihood ratio of 0.11 (Guerriero et al., 1998). Deep endometriosis in the bladder wall or rectum may be visualised with TVS (Dessole et al., 2003). Trans Rectal Sonography (TRS) may also be useful for diagnosing rectovaginal endometriosis (sensitivity 80-100%, specificity 96-100%) (Fedele et al., 1998). TRS performs better than magnetic resonance imaging (MRI) in the diagnosis of rectal involvement for patients presenting with deeply infiltrating endometriosis. For the diagnosis of rectal involvement, sensitivity, specificity, PPV and NPV for TRS were 97.1%, 89.4%, 86.8% and 97.7% and for MRI they were 76.5%, 97.9%, 96.3% and 85.2% (Chapron et al., 2004).

Magnetic resonance imaging

At present, there is insufficient evidence to indicate that magnetic resonance imaging (MRI) is a useful test to diagnose or exclude endometriosis compared to laparoscopy.

Blood tests

A

Serum CA-125 levels may be elevated in endometriosis. However, compared to laparoscopy, measuring serum CA-125 levels has no value as a diagnostic tool (Mol et al., 1998).

Systematic review of diagnostic tests

Investigations to assess disease extent

GPP

If there is clinical evidence of deeply infiltrating endometriosis, ureteral, bladder, and bowel involvement should be assessed. Consideration should be given to performing MRI or ultrasound (trans-rectal and/or trans-vaginal and/or renal), with or without IVP and barium enema studies depending upon the individual circumstances, to map the extent of disease present, which may be multi-focal.

Assessment of ovarian cysts

GPP

Local guidelines for the management of suspected ovarian malignancy should be followed in cases of ovarian endometrioma. Ultrasound scanning ± serum CA-125 testing is usually used to try to identify rare instances of ovarian cancer; however, CA-125 levels can be elevated in the presence of endometriomas.

Laparoscopy

GPP

Good surgical practice is to use an instrument such as a grasper, via a secondary port, to mobilise the pelvic organs and to palpate lesions which can help determine their nodularity. It is also important to document in detail the type, location and extent of all lesions and adhesions in the operative notes; ideal practice is to record the findings on video or DVD.

GPP	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.

B

All classification systems for endometriosis are subjective and correlate poorly with pain symptoms, but may be of value in infertility prognosis and management (Chapron et al., 2003b; D'Hooghe et al., 2003b).

Evidence Level 3

B

At laparoscopy, deeply infiltrating endometriosis may have the appearance of minimal disease, resulting in an underestimation of disease severity (Koninckx et al., 1994).

Evidence Level 3

Laparoscopy is the gold standard for diagnosing endometriosis, although recognition of endometriosis will vary with the experience of the surgeon, especially for subtle, bowel, bladder, ureteral and diaphragmatic lesions. A meta-analysis of its value against a histological diagnosis showed (assuming a 10% pre-test probability of endometriosis) that a positive laparoscopy increases the likelihood of disease to 32% (95% CI 21 to 46%) and a negative laparoscopy decreases the likelihood to 0.7% (95% CI 0.1 to 5.0%) (Wykes et al., 2004). However, diagnostic laparoscopy is associated with an approximately 3% risk of minor complications (e.g. nausea, shoulder tip pain) and a risk of major complications (e.g. bowel perforation, vascular damage) of between 0.6 to 1.8 per 1000 (Chapron et al., 1998; Harkki-Siren et al., 1999).

At diagnostic laparoscopy, the pelvic and abdominal cavity should be systematically searched for the presence of endometriosis. This must include a complete and systematic inspection and palpation with a blunt probe of the bowel, bladder, uterus, tubes, ovaries, cul-de-sac, broad ligaments and the bottom of peritoneal pockets and hernial sacs. The diagnosis of ovarian endometriosis is facilitated by careful inspection of both ovaries in their entirety, which may be difficult when adhesions are present in more advanced stages of the disease. Endometriosis can be treated during laparoscopy, thus combining diagnosis and therapy.

Because chocolate like fluid may also be found in other types of ovarian cysts, such as haemorrhagic corpus luteal or neoplastic cysts, biopsy and preferably removal of the cyst for histological confirmation is recommended if the cyst is > 3 cms diameter. Ovarian endometriosis as a single finding occurs in < 1% of endometriosis patients, the rest having mostly pelvic and/or intestinal endometriosis as well (Redwine, 1999).

Classification systems

Many classification systems have been proposed, but only one has been generally accepted. This is the revised American Fertility Society (AFS) system (ASRM, 1997). It is based on:

1. the appearance, size, and depth of peritoneal and ovarian implants;
2. the presence, extent and type of lesions: red (red, red-pink, and clear), white (white, yellow-brown, and peritoneal defects) and black (black and blue);
3. the presence, extent, and type of adnexal adhesions and the degree of cul-de-sac obliteration.

Colour photographs are provided by ASRM to assure consistency in describing the appearance. This system reflects the extent of endometriotic disease, but has considerable intra-observer and inter-observer variability (Hornstein et al., 1993; Lin et al., 1998).

Moreover, as the system was developed primarily for the management of infertility, adnexal adhesions contribute disproportionately. Similarly, they do not correlate with the signs and symptoms of the disease, nor with the results of treatment. There are no data to demonstrate that classifying the lesions contributes to any clinical outcome measures.

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