Author Name: Dr. Hina Ali || Mentor Name: Dr. Anuja Singh on April 25, 2020

INTRODUCTION
The overall incidence of endometriosis is 10%. It is generally seen in adolescents and women of reproductive age group.

Endometriosis occurs when tissue like inner lining of uterus i.e. endometrium grows outside the uterus like in ovaries, around ligaments of uterus, bladder and bowel etc.

During a month, endometrial tissue lining the inside of uterus grows under the effect of hormones and start bleeding during menses. Endometrial tissue present outside the uterus also grows in the same way and starts bleeding but as it is outside the uterus, it cannot shed and come out through vagina. Instead inflammatory process starts in these areas causing adhesions and scarring leading to pain.

Average time taken in diagnosis of endometriosis since the onset of symptoms is of 7-10 years. During these years, patient keeps on changing doctors to reach to a diagnosis and treatment.

FACTORS RESPONSIBLE FOR THE DELAY IN ENDOMETRIAL DIAGNOSIS

1. Patient and Doctor
Most common symptom of endometriosis is dysmenorrhea i.e. pain during menses which is usually considered as normal phenomena by patient. Also patient conceal associated symptoms like dyspareunia (painful sex), pelvic pain, low back ache, dysuria (painful micturition) and dyschezia (painful defecation). Many patients are not able to communicate about their painful intercourse and its severity properly due to embarrassment.

Doctors usually find it difficult to differentiate between primary and secondary dysmenorrhea especially in adolescents and council the patient that it is part of being a women and there is nothing to worry. They usually prescribe NSAIDS (non-steroidal anti-inflammatory drugs) or OCPs (oral contraceptive pills) empirically for dysmenorrhea. Using these medications, symptoms initially reduce thereby further leading to delay in diagnosis of endometriosis.

Dysmenorrhea which increase after initial relief or no improvement on NSAIDS and OCPs should raise suspicion of endometriosis.

Patients with infertility or subfertility due to endometriosis are usually diagnosed earlier than patients with endometriosis alone.

2. Symptoms
Initially the disease is asymptomatic in majority of cases. Also the most common symptom is pelvic pain so whenever such patient present to a doctor, she is sent for ultrasound which is normal in majority of cases.
Patients of endometriosis many a times have urinary or bowel complaints due to which they get referred to urologist or gastroenterologist further delaying their diagnosis. This leads to frustration in patient causing psychological issues like depression.

So there is wide range of symptoms which overlap with various other gynecologic and non- gynecologic conditions like pelvic infections, ovarian cysts, irritable bowel syndrome, cystitis, fibroids, adhesions and depression.
Therefore, diagnosis usually get delayed as there is no specific sign and symptom of endometriosis.

3. Diagnosis
No blood or urine test can diagnose endometriosis.
Transvaginal sonography is normal in early stages of endometriosis when lesions are small i.e. not a very sensitive test in stage 1. However it can detect cysts that form in ovaries or adhesions which make the pelvic organs less mobile but these are seen in late stages of endometriosis.

Laproscopy with histologic confirmation of endometriotic lesions is the gold standard test for endometrial diagnosis. Laproscopy is an operation in which a camera is inserted in the abdomen and pelvis is screened for endometriotic lesions. It is minimally invasive but still it is invasive that’s why it is generally not acceptable for making a diagnosis. Also small endometriotic lesions are missed by cameras on laproscopy.

CONCLUSION
There is difficulty in diagnosing endometriosis due to non-specific symptoms,and lack of specific marker of the disease. Also there is lack of awareness plus social stigma involved.
For endometrial diagnosis , doctor should have early suspicion and should not ignore even the mildest symptom told by patient.

If patient present with complaints like
● Abdominopelvic pain, severe dysmenorrhea, menorrhagia, sub fertility, dyspareunia and post coital bleeding.
● Dysmenorrhea not responsive to NSAIDS or OCPs.
● Dysmenorrhea leading to absenteeism from school or office.
● Dysmenorrhea leading to frequent visit to emergency.
● History of endometriosis in mother or sister.
● Sub fertility with regular menses, patent tubes and normal semen analysis.
● Urinary complaints like frequency, urgency or pain without any other obvious cause.
● Bowel complaints like diarrhea, constipation, dyschezia or cramping without any diagnosis.

Doctor should start treatment on clinical suspicion and should not wait for laproscopy to confirm the diagnosis. Also a gynaecologist who is more experienced with the disease can make early diagnosis than a primary care physician, so a timely referral should be done by the same.

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