Endometriomas and Pelvic Endometriosis

Abstract

Endometriosis affects between 6 and 10 % of women in the reproductive age range, and this frequency rises to 35–50 % for women who also experience pain and/or infertility. Although it is not possible to detect peritoneal endometriosis with imaging, transvaginal sonography (TVS) has been demonstrated to have a high accuracy for the diagnosis of ovarian endometrioma, deep infiltrating endometriosis (DIE) of the bowel and pelvic adhesions. Endometriomas are associated with subfertility, particularly if pelvic DIE is also present. In addition, endometriomas appear to be strongly associated with ovarian fixation and pouch of Douglas (POD) obliteration. Pelvic adhesions are important to identify preoperatively, as POD obliteration is associated with a threefold increase in the risk of bowel DIE and bowel surgery. POD obliteration may be diagnosed preoperatively using the dynamic, real-time TVS uterine ‘sliding sign’. Women with a negative sliding sign (i.e. POD obliteration) should be referred to an advanced laparoscopic surgeon and/or colorectal surgeon due to their high risk of complex adhesions and bowel DIE. With regard to the TVS diagnosis of pelvic DIE, a recent meta-analysis indicated that TVS and enhanced TVS techniques are highly accurate for the prediction of rectal/rectosigmoid DIE; however, the same does not hold true for other pelvic DIE locations (uterosacral ligaments, vagina, rectovaginal septum). A global consensus is needed regarding the criteria for the TVS diagnosis of the various locations of pelvic DIE, which would in turn allow for the development of a standardized specialized TVS assessment for women with pelvic pain and/or infertility.