Endometriosis Diagnosis

According to the characteristics of Endometriosis,where women of childbearing age have dysmenorrhea or infertility history, gynecological check is palpable within a pelvic mass or activity nodules,the general of the preliminary diagnosis is endometriosis. The condition is slightly complicated, and can be further use of these laboratory tests and special methods for diagnosis, general diagnosis is not difficult, but in the diagnosis of the process must be asked in detail about the history of serious gynecological examinations, especially the triple gynecological clinic inspection, a comprehensive analysis of the disease in order to arrive at a correct diagnosis.

Differential Diagnosis:
For the general diagnosis of the disease according to history of clinical symptoms and signs can make diagnosis easier, but in the course of disease diagnosis must want attention and identification of the following diseases:
1. Ovarian malignancy in patients with bad general, the progression of the disease quickly, usually accompanied by persistent abdominal pain, abdominal distension. Gynecological examination, and palpable pelvic mass, if the pelvic nerve tumor suppression or tumor necrosis bleeding, can occur in the lower abdomen and lumbosacral pain, accompanied by ascites. B ultrasonic examination showed that for the solid tumor, or mixed, irregular.
2. Pelvic Inflammatory Mass attachment many inflammatory mass caused by inflammation or tuberculosis asked in detail about history, has many patients with acute pelvic infection and recurrent history or history of tuberculosis. Not only in patients with menstrual pain, but usually also accompanied by abdominal pain, accompanied by fever, by the anti-inflammatory or anti-tuberculosis treatment. Gynecologic examination can be unilateral or bilateral palpable and non-attachment zone boundary due to activity of the mass-ching, general sticky on the back of the uterus such as with pelvic endometriosis difficult differential diagnosis when there is a viable B-ultrasonography or iodine Hysterosalpingography Oil angiography further clarify the diagnosis.
3. Adenomyosis patients may also have dysmenorrhea, but the general uniformity of the uterus increased quality hardware. Inspection obvious menstrual uterine tenderness, and menstrual uterus has increased, narrowing the uterus after menstruation characteristics. B ultrasonic examination can be seen within the irregular myometrial echogenic usually a result of adenomyosis and pelvic endometriosis coexist attachment area therefore sometimes may also be palpable mass.
4. Rectal cancer patients often bloody stool or hematochezia, and menstrual symptoms are not affected. Doctor anal finger sets of blood when there is pelvic endometriosis in a serious condition may cause the rectum rectum violations narrow, with stool, or even defecate blood,required phase differential with rectal cancer. Feasible barium enema or rectal endoscopic examination confirmed the diagnosis.
5. And gynecology, surgical acute abdomen because of the differential ovarian endometriosis rising incidence of so endometriosis cyst rupture incidence is also rising. When the cyst broke down, because of substantial capsule contents have spilled into the abdominal cavity can not be tolerated sudden severe abdominal pain, at this time is often misdiagnosed as ectopic pregnancy, ovarian cyst torsion, appendicitis, peritonitis, such as women's surgical diseases. Therefore, in the course of disease diagnosis, should be carefully asked about the history of the past, know whether there is a history of endometriosis, history of fever history of menopause, such as help to carry out differential diagnosis.

Laboratory examinations:
Check 1.CA125 ovarian cancer associated antigen CA125 from the body cavity are epithelial cell surface antigen, is a polymeric glycoprotein, mainly in endometrial, cervical intraepithelial tubal, peritoneal, pleural and pericardial membrane. These organizations CA125 cell surface antigen shedding into the body cavity. In the blood of cervical mucus, milk saliva, amniotic fluid and peritoneal fluid and other body fluids of higher concentrations of both the expression of CA125 in saliva have a high serum concentration than 1-fold in peritoneal fluid than in blood concentrations 100 times higher concentration of CA125 fluctuate with the menstrual cycle endometrium at proliferative phase cycle to a minimum, luteal phase began to rise, the highest ovarian tumor menstrual period, pelvic inflammatory disease, endometriosis and early pregnancy, such as increasing the concentration of CA125. Change in serum concentration with lesion size and severity of lesions was positively correlated to indicators of clinical diagnosis on the above diseases, and monitoring the disease prognosis and assessment of efficacy. Because of CA125 in different diseases can occur between cross-reaction, so that it alone can not lower specificity as a diagnostic indicator.
Patients with endometriosis of the CA125 concentration in body fluids, elevated concentrations and endometriosis a positive correlation of clinical and fluctuate with the menstrual cycle, a feature that helps to identify endometriosis with other gynecological diseases. CA125 serum concentration and disease stages is proportional to the concentration of serum CA125 for the diagnosis of ≥ 35U/ml endometriosis standard, the sensitivity 44%, specificity 88% about 72% positive predictive rate, negative prediction rate of 70%. The concentration of CA125 in peritoneal fluid may be a direct response to endometriosis patients, serum concentration of more than 100 times. Therefore its significance than the serum, and are diagnosed with mild endometriosis an important means of peritoneal fluid for concentration ≥ 2500U/ml, the diagnostic sensitivity and 83% specificity 64%, positive prediction rate of 57% and negative predictive rate was 88% but the specificity is not high. Combined with the B-such as CT or MRI, may improve the diagnosis rate. In addition, preoperative determination of CA125 help select the time of laparoscopic seized. Such as elevated preoperative CA125, suggesting that there is ectopic lesions exist, select lesions increase during menstruation, bleeding, the peritoneal surface when there is positive performance of laparoscopy can reduce the misdiagnosis rate of seizure
2. Endometrial antibody anti-endometrial antibodies in endometriosis are a sign of antibodies, their target antigens are endometrial glandular cells in a progesterone-dependent glycoprotein, molecular weight of 26,000 ~ 40,000 of its generated and ectopic endometrial stimulation and immune-related environmental imbalance. Many scholars use different methods to detect endometriosis in patients with blood containing anti-endometrial antibodies, the sensitivity at 56% ~ 75% and specificity at 90% ~ 100%. Patients with danazol and GnRHa treatment, serum anti-endometrial antibodies significantly reduced. Therefore, determination of anti-endometrial antibodies contribute Endometriosis Diagnosis and Clinical Observation.

Other auxiliary examinations:
1. Imaging diagnosis
(1) Ultrasonography: Ultrasonography is usually applied to endometriosis stage Ⅲ ~ Ⅳ patients with pelvic endometriosis formed cysts, mostly ovarian chocolate cyst. Ultrasonography is not easy to distinguish with the ovarian tumor, need to combine clinical and other examinations to be differential. Generally can be at pelvic exploration and single or multiple cysts, cyst diameter, usually 5 ~ 6cm rarely> 10cm. Because of the blood and fiber deposition machine endometriosis thicker wall and rough, many cysts in close adhesion with surrounding tissue, in particular, more restrictive adhesions with the uterus. Menstrual period because of cyst hemorrhage, B can be slightly increased under the super. Generally ovarian endometriosis Ultrasonogram divided into 4 types: cyst type, many mixed cystic and solid
① diffuse adenomyosis Ultrasonogram:
A. uterus increases: the uterus was increased uniformity in the longitudinal or cross-section often show a more anterior uterine wall thickening significantly. Uterine size ≤ 3 for many months of pregnancy the uterus of its three and the average diameter of> 20cm or so often. Uterine smooth surface, spherical patterns often. It was found at the size of the uterus before and after the menstrual period often changes, namely increased uterine myometrium at menstrual phase fluid within the small dark area significantly. Menstrual period in the uterus is relatively smaller than the menstrual period. This may be associated with myometrial hematocele within a small pocket of blood in part be absorbed as well as post-menstrual period was to improve the uterine hyperemia.
B. internal echo: diffuse type according to the pathological adenomyosis different organizational structure, its internal echo has two kinds:
a. Liquid levy a small dark area: because of the diffuse type of the myometrium there was proliferative phase or secretory phase reaction of ectopic endometrium Island, its expansion of ectopic endometrial glands, glandular cavity containing protein liquid or obsolete blood, resulting in the formation of myometrial scattered with small cysts and ectopic endometrium surrounding smooth muscle cells and fibrous connective tissue showed reactive hyperplasia. In such a pathology exists between the organizational structure of a strong acoustic impedance interface. So show up at Ultrasonogram increase uniformity within the myometrium have scattered in the form of irregular size, ranging from liquid levy small dark area at the small dark area surrounding shows uneven distribution of the strong points of light echo. Light point and dark area usually constitute a weaving-like symptoms each other.
b. strong echo area: its pathologic characteristics of the organizational structure of myometrial interstitial cells only and showed reactive hyperplasia of smooth muscle cells and fibrous connective tissue and no ectopic endometrial glandular elements, the difference between the two silent interface impedance . Therefore show up Ultrasonogram increase uniformity within the myometrium only see a uniform distribution is still strong echo light point, often after the wall is clear, and show that no solution of the small dark area of audio-visual map, that is, interstitial uterine adenosis muscle.
② localized adenomyosis Ultrasonography: Ultrasonography showed increased uterine mostly irregular, uneven surface, a small number of normal uterine size. Vertical and horizontal cross-section in the womb can be seen on both single or multiple real heterogeneity Light Mission, the internal echo of the strong echo of the main points of light, there is a small amount of dispersion between the uneven distribution at the low echo or fluid of the small dark area. Light Mission often located in the posterior wall of the uterus and bilateral uterine corner, slightly protruding. Penetration to the uterine cavity can also be similar to submucous myoma. But no matter what kind of plane for scanning, are only shows the side of tumor penetration to the uterine cavity and myometrial Another Example linked with the boundaries between myometrial unclear, there is no tumor and submucous myoma pedicle often have tumor pedicle, and the heterogeneity of the real-ray Mission (tumor) in the uterine cavity.
Localized adenomyosis also known as Adenomyoma size generally <3.0cm, 1.0cm often. Adenomyoma be a small number of> 7.0cm, like uterine fibroids, but without the sound back to the dark pseudocapsule.
③ merger Ultrasonogram hysteromyoma: two types of merging Adenomyosis may hysteromyoma. Sonographic features of their uterus increases markedly, often irregular shape. In the uterine longitudinal and cross-sectional diagram can be simultaneously shown on adenomyosis and uterine fibroids sonographic characteristics, both in audio and video are not always easy to distinguish map.
④ combined pelvic endometriosis Ultrasonography: Ultrasonography at up except in the uterine section showing adenomyosis Ultrasonographic Characteristics in the womb can also be unilateral or bilateral concave attachment area or rectum showed cystic mass, that is, ovarian chocolate cysts or irregular-shaped hypoechoic Xiao Guang Mission (pelvic endometriosis nodules) chocolate cysts Sonographic characteristics: A. was the non-purity of the cystic mass that is intracapsular fluid was dark interval of scattered light echo point, many bright points accumulated at the bottom of the capsule, such as with pressure probe vibration mass, the visible light resulting floating point B. cyst wall thick. Have showed their rear adducin-like enhancement. C. many cyst located behind the uterus, and adhesions with the uterus. Pelvic endometriosis nodules often located in the rectum of uterine Au, sacral ligament, posterior uterine serosal surface in vertical and horizontal scanning when the uterus can often show a number of positions in the above-mentioned <2.0cm size, shape irregular low Echo Light Mission. Hydroma law such as the use of rectal or vaginal pelvic scanning probe, such sonographic features of a more explicit.
2. Hysterosalpingography (HSG) Endometriosis HSG image characteristics: ① Metrorrhagia increased Gongti have small cystic shadow edge; ② womb dendritic or torch-shaped shadow of the Palais and Palace at the end of both sides of the brush-like fate has changed; ③ bilateral fallopian tubes can be pressure, but also because of adhesions and widened; ④ contrast agent within the pelvic uneven dispersion.
Ectopic foci outside the uterus can be the site of lesion line chest, rectal endoscopic examination. There is at suspicious ectopic urinary tract lesions may be pyelography, and retrograde secretion of contrast can be part of the diagnosis of obstructive; lesions spread to the bladder, the bladder microscopy feasible. Ectopic B-ovarian chocolate cysts can be found without the characteristic. Lesion biopsy and treatment with hormone tests are very helpful for diagnosis
3.CT and MRI examination of most of the patients to the diagnosis and follow-up ultrasound-based diagnosis, CT scan showed many borders, contour unclear, uneven density of the lesions showed that there is bleeding for high-density to low density local effusion.
The performance of MRI and changeable, according to pulse sequence used and the lesions in different components vary. Completely hemorrhagic lesions at T1, T2-weighted images for the homogeneous high signal density, T2-weighted images on the signal increased. Uterine adenomyoma more often contain divalent iron ions, and its response to the magnetic effects can cause lesions of the lower signal, especially in T2-weighted images on a more significant effect on diagnostic accuracy.
MRI of the ovary, rectum Vagina intervals around the vagina between the rectosigmoid endometriosis foci showed good, but the peritoneum and ligaments of the ectopic foci showed poor.
The use of transvaginal B-and T2-weighted MRI images of the determination of the thickness of the uterus to connect (JZ) assist in diagnosis of adenomyosis. Its diagnosis is based on adenomyosis for the pathological changes of endometrial glands and (or) depth of endometrial stromal and myometrial junction. MRI Determination of adenomyosis average JZ thickness, respectively (15.0 ± 4.9) mm, normal (7.7 ± 3.3) mmMRI diagnosis of adenomyosis JZ thickness optimal threshold for ≥ 12mm, the sensitivity was 93% and specificity of 91%, positive predictive value of transvaginal B-for 71%, MRI was 65%, whichever is no significant difference. B vaginal ultrasound and MRI in the diagnosis of adenomyosis on the correctness of the same, but other plant in the diagnosis of lesions on CT and MRI of little significance.
Although laparoscopic diagnosis of endometriosis of the best way, but are invasive surgery, high cost and should not be repeated to check the restrictions, and CA125 measurement, CT and magnetic resonance of non-invasive method of examination can be repeatedly.
4. Laparoscopic extensive review at the pre-laparoscopic era, the diagnosis of endometriosis and a history of major depend on histopathological examination. For the conduct of its typical symptoms of secondary dysmenorrhea (by 1 ~ 2 days before menstrual start 1 ~ 2 days after the disappearance), infertility, intercourse discomfort or pain and bowel pain or tenesmus, urinary frequency or hematuria, the inter-period pain should be highly suspected to be endometriosis. Gynecological examination the uterus fixed retroflexion, uterine sacral ligament uterine crassa nodular rectal pain Department nodules, unilateral or bilateral ovarian enlargement and tenderness, it is even more to support the diagnosis.
Because of the scope of endometriosis lesions greater variability, small lesions difficult to find. Reported in the literature such as only the basis of clinical diagnosis and misdiagnosis rate of up to 40.7 percent, missed diagnosis rate was 17.8%, even if the application of B-ultrasonography hard found by the American Fertility Society (AFS) staging Ⅰ Phase Ⅱ cases of laparoscopic or direct observation lesions and to do biopsy to determine the existence of endometriosis, especially for asymptomatic women or symptoms of severe pathological examination but negative to the early diagnosis. Laparoscopy can also be an accurate determination of lesion extent of uniform phases and in accordance with the phased select appropriate treatment.
(1) laparoscopy indications:
① infertile women were found by screening abnormal.
② suspected infertile women have endometriosis ovarian cyst diameter of> 3 ~ 5cm..
③ pelvic pain and unexplained symptoms were obvious.
④ pelvic pain associated with ovarian cyst diameter of> 3 ~ 5cm.
⑤ Hysterosalpingography image abnormalities such as parasols or bayonet-like mushroom-
(2) the timing of laparoscopy: diagnostic laparoscopy in the menstrual cycle can be implemented at any time. Such as endometriosis clinical suspicion exist, then the best at menstruation menstrual period or the day before yesterday, imposed because of endometriosis lesions at this time more obvious, and even the surface of visible lesions hemorrhagic activity. In addition or see the end of menstruation and umbrella counter-current situation such a performance drop of blood will not only contribute to the diagnosis, but also could explain why some women even though the small and less stove plant it is so severe dysmenorrhea.
(3) laparoscopic observation procedures: should conduct a comprehensive observation of the entire pelvic cavity, in the uterine manipulator and blunt-shaped rough bougie under the guidance of the order of exposed pelvic peritoneum and organs, inspection of each MCD will not be missed. First uterine backward movement, so as to facilitate observation of the uterus, bladder and Department peritoneal surface, round ligament of the uterus and then move forward bit, and turned separately on both sides of fallopian tube and ovarian observation, with bougie lifted ovary, careful observation Finally the detection of ovarian noodle rectum uterus and uterine Department whether sacral ligament lesions. Such as the uterus rectum plot should have more liquid net absorption so that they can see the pelvic peritoneum and the surface of the uterus per sacral ligament in Example conventional exploration shall appendiceal and colon, so that the correct phases.

The naked eye and microscope observation:
① endometriosis good site for ovarian, uterine-sacral ligament, uterine rectal, ovarian fossa, uterine bladder and pelvic peritoneum. The most affected parts of the above-mentioned reasons, presumably because of blood reflux, the blood in the endometrial debris crashed into the pelvic cavity due to gravity due to the depths. Ovarian fallopian tube close to the surface uneven ovarian umbrella and frequent occurrence of ovulation-hole wound, but also increase its susceptibility to endometriosis, endometriosis has become the most common site of.
② endometriosis lesion size, color and shape, look very different. Typical lesions manifested as dark-brown pigmentation damage. Start bleeding bright red for blue or purple lesions were hemoglobin gradually become stained brown or dark purple Finally white stellate scar formation. The beginning of hair is often described as "powder burn" lesion diameter <2mm, which lasted long after the lesions such as "mulberry-like", a single lesion diameter of about 2 ~ 5mm some integration into the formation of clumps or cysts. It seems confined to the surface of such lesions, lesions in fact very different from the depth of some lesions, therefore, see only "the tip of the peak."
Atypical lesions for many non-pigmented lesions, including: A. Retroperitoneal white opaque area, with or without thickening. B. Peritoneal red flame-like damage, often protruding peritoneal surface of the peritoneal surface C. gland neoplasm. D. circular peritoneal defects, or peritoneal window for the scar and possible damage to the formation of peritoneal edge lectin. E. under ovarian adhesions, ovarian and ovarian nest below between peritoneal lesions. These atypical lesions by biopsy confirmed the diagnosis of endometriosis was 45% ~ 81%.
Under the microscope endometriosis plant species have been scanning electron microscopy confirmed that, but such damage laparoscopic view of the naked eye can not see. Murphy and other reported cases of known endometriosis to do the normal random peritoneal biopsy using scanning electron microscopy to identify 25% confirmed to be endometriosis lesions.
Because of atypical endometriosis lesions or microscopic seed plants exist, only the naked eye to determine the number of peritoneal and size of plant species can not reflect the severity of the disease.
③ ovarian superficial lesions because of repeated cyclical bleeding, caused by inflammatory response to pelvic adhesions Organize. Easily fixed in ovarian ovarian ovarian nest near the door. Laparoscopic see the appearance of normal but there is adhesion of the ovary, endometriosis should be considered suspicious; separate adhesions after spill such as chocolate-like liquid, that is, diagnosis of endometriosis has value.
With the course of the development of ovarian sticking closely to the ovarian fossa, posterior lobe broad ligament, pelvic sidewall and pelvic floor. However, sometimes the appearance of the normal ovarian volume can be increased at the rear with the other side of the uterus sticking together become the kiss of ovarian ovary.
④ ovarian chocolate cyst formation was also sexual. Early lesions, the ovarian surface or cortex appear blue purple vesicles, after fusion to become cysts, sizes up to 8 ~ 10cm in diameter or larger, often bilateral thin wall, has not yet formed when adhesion was typical purple Blue said ovarian endometriosis or endometrial ovarian tumor. Lesions when the cyst since the beginning of the free, smooth surface; for growth after the close adhesion with the surrounding tissue. Intraoperative cyst rupture or puncture can be seen when the brown liquid such as chocolate syrup, it also called the ovarian chocolate cyst.
⑤ pelvic peritoneal endometriosis is also a good site, and multiple pelvic lesions often co-exist. Pelvic endometriosis in patients with effusion were higher than normal for many women, ranging from 10 ~ 130ml, normal women <10ml for many lesions when menstrual bleeding caused by bright red blood, compared with the old non-menstrual blood or hemosiderin stained brown due to peritoneal deposition of pelvic peritoneal lesions in addition to the above exist outside often can be seen in the deep pelvic pseudocyst. This is because the blood flow to stimulate the pelvic peritoneum, caused by connective tissue caused by reaction happened parcels.
⑥ Endometriosis lesions can be directly affected fallopian tube, or due to extensive pelvic organizations involved so that tubal adhesions, but the fallopian tubes themselves are often open. In serious cases, sticky tight rectum in the posterior wall of the uterus so the uterus rectum partial or complete atresia.
5. Biopsy of suspected endometriosis lesion biopsy should be done to provide a diagnosis of normal histology. Biopsy should be taken to safe areas, that is, away from important organs and blood vessels, not complicated by injury and bleeding, uterine rectal sacral ligament uterine and ovarian biopsy are the ideal surface part.
Pathological diagnosis of endometriosis based primarily on the basic structure of four under the microscope, that is, endometrial epithelium, glands (or adenoid structures), interstitial and bleeding. Known continuous function has endometriosis lesions with endoscopic features of the destruction of its tendency, therefore, early lesions often show a typical histology, and size of ovarian chocolate cyst, endoscopic probably show only a hemosiderin macrophages, with varying amount of inflammatory cells and fibrous connective tissue. Importantly, endometrial stromal happen are the causes of bleeding, not glandular or epithelial, so even if only to exist between the quality, but also sufficient to consider the characteristics of the Department of the disease.
Because of clinical practice are often unable to obtain sufficient biopsy material, and 1 / 3 biopsy specimens could not confirm the typical histology characteristics, only in the endometriosis lesions found in red blood cells, hemosiderin or hemosiderin filled with giant macrophages and other evidence of bleeding, when combined with clinical symptoms and can only be seen visually, the pathological characteristics of endometriosis to make the diagnosis, but should pay attention to the exclusion of other diseases exist.

Related inspections:
> CA125
> Determination of clotting time
> Anti-endometrial antibodies