eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Endometriosis: Differential Diagnoses & Workup

Author: Turandot Saul, MD, Staff Physician, Department of Emergency Medicine, Bellevue Hospital Center/New York University Medical Center
Coauthor(s): Ami K Davé, MD, Assistant Professor, Department of Emergency Medicine, New York University School of Medicine; Assistant Residency Director, Department of Emergency Medicine, New York University/Bellevue Hospital Center
Contributor Information and Disclosures

Updated: Feb 14, 2008

Differential Diagnoses

Appendicitis, Acute
Pregnancy, Ectopic
Diverticular Disease
Urinary Tract Infection, Female
Ovarian Cysts
Ovarian Torsion
Pelvic Inflammatory Disease

Other Problems to Be Considered

Adenomyosis
Colon cancer
Ovarian cancer

Workup

Laboratory Studies

  • In the ED setting, few laboratory tests prove to be valuable in the diagnosis of endometriosis.
    • CBC with differential may help differentiate pelvic infection from endometriosis as well as assess the degree of blood loss.
    • Urinalysis and urine culture should be sent if urinary tract infection (UTI) is in the differential.
    • Cervical Gram stain and cultures should be considered because STDs can also cause pelvic pain and infertility.
    • Beta human chorionic gonadotropin (HCG) can rule out complications of pregnancy.

Imaging Studies

  • Routine radiographs are not recommended unless other disease entities requiring these studies are in the differential diagnosis.
  • Endometriosis can be assessed by either transvaginal ultrasonography or endorectal ultrasonography.  The sonographic features of endometriomas vary from simple cysts to complex cysts with internal echoes to solid masses, usually devoid of vascularity. 
  • Magnetic resonance imaging (MRI) offers a superior combination of 3D imaging with high-resolution special and temporal resolution, low observer dependency, no radiation exposure, and none of the risks associated with iodinated contrast agents.
    • With dynamic contrast-enhanced MRI, dynamic changes in MR signal intensity in selected tissues can be detected. Some of the newer generation contrast agents can be loaded with specific antibodies that allow for targeted imaging.
    • MRI has a higher sensitivity for detecting pelvic masses than ultrasonography but is limited in identifying diffuse pelvic endometriosis.
  • Using CT, endometriomas may appear as cystic masses, but their appearance is nonspecific and CT should not be relied on for diagnosis. Complications of endometriosis, including bowel obstruction and hydronephrosis, may be seen on CT.
  • Hysterosalpingography may reveal tubal occlusion or periadnexal adhesions.

Other Tests

  • A new diagnostic test has been based on the detection of autoantibodies against Thomsen-Friedenreich (T) antigen (Gal beta1-3GalNAc) bearing proteins. The sensitivity and specificity of the test are 80%. This test may prove useful in the outpatient setting.
  • CA 125 is a marker that may also be useful in the outpatient setting but is not a useful tool for an initial screening.
  • Another office test is the marker CCR1. The expression of the blood-borne marker CCR1 mRNA in peripheral blood leukocytes is significantly higher in women with endometriosis compared with unaffected women.

Procedures

  • Laparoscopy with biopsy is the only definitive way to diagnose endometriosis. It is an invasive procedure with an overall sensitivity of 97% and a specificity of only 77%. Hallmark findings are the classic powder burn, blue-black lesions.
  • The most common sites of involvement found during laparoscopy are the following, in descending order:
    • Ovaries
    • Posterior cul-de-sac
    • Broad ligament
    • Uterosacral ligament
    • Rectosigmoid colon
    • Bladder
    • Distal ureter

More on Endometriosis

Overview: Endometriosis
Differential Diagnoses & Workup: Endometriosis
Treatment & Medication: Endometriosis
Follow-up: Endometriosis
References
[ CLOSE WINDOW ]

References

  1. Adamson, GD, Nelson, HP. Surgical treatment of endometriosis. Obstet Gynecol Clin North Am. 1997;24:375-409. [Medline].

  2. Mounsey AL, Wilgus A, Slawson DC. Diagnosis and management of endometriosis. Am Fam Physician. Aug 15 2006;74(4):594-600. [Medline].

  3. Brosens IA. New principles in the management of endometriosis. Acta Obstet Gynecol Scand Suppl. 1994;159:18-21. [Medline].

  4. Buchweitz O, Poel T, Diedrich K, Malik E. The diagnostic dilemma of minimal and mild endometriosis under routine conditions. J Am Assoc Gynecol Laparosc. Feb 2003;10(1):85-9. [Medline].

  5. Busacca M, Chiaffarino F, Candiani M, Vignali M, Bertulessi C, Oggioni G. Determinants of long-term clinically detected recurrence rates of deep, ovarian, and pelvic endometriosis. Am J Obstet Gynecol. Aug 2006;195(2):426-32. [Medline].

  6. Carlson KJ, Nichols DH, Schiff I. Indications for hysterectomy. N Engl J Med. Mar 25 1993;328(12):856-60. [Medline].

  7. Espindola D, Kennedy KA, Fischer EG. Management of abnormal uterine bleeding and the pathology of endometrial hyperplasia. Obstet Gynecol Clin North Am. Dec 2007;34(4):717-37, ix. [Medline].

  8. Eskenazi, B, Warner, ML. Epidemiology of Endometriosis. Obstet Gynecol Clin North Am. 1997;24:235-258. [Medline].

  9. Hummelshoj L, Prentice A, Groothuis P. Update on endometriosis. Women's Health. 2006;2(1):53-56.

  10. Mukund J. Sonography of adnexal masses. Ultrasound Clinics. January 2007;2.

  11. Jubanyik KJ, Comite F. Extrapelvic Endometriosis. Obstet Gynecol Clin North Am. 1997;24:411-440. [Medline].

  12. Kennedy S, Bergqvist A, Chapron C, et al. ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod. Oct 2005;20(10):2698-704. [Medline].

  13. Kingsberg SA, Janata JW. Female sexual disorders: assessment, diagnosis, and treatment. Urol Clin North Am. Nov 2007;34(4):497-506, v-vi. [Medline].

  14. Lu PY, Ory SJ. Endometriosis: Current Management. Mayo Clin Proc. 1995;170:453-463. [Medline].

  15. Mahmood TA, Templeton A. Prevalence and genesis of endometriosis. Hum Reprod. Apr 1991;6(4):544-9. [Medline].

  16. Markham SM, Carpenter SE, Rock JA. Extrapelvic endometriosis. Obstet Gynecol Clin North Am. Mar 1989;16(1):193-219. [Medline].

  17. Prentice A. Regular review: Endometriosis. BMJ. Jul 14 2001;323(7304):93-5. [Medline].

  18. Lobo RA. Endometriosis: etiology, pathology, diagnosis, management. In: Katz VL, ed. Comprehensive Gynecology. 5th ed. Philadelphia, PA: Mosby; 2007:chap 19.

  19. Shepard MK, Mancini MC, Campbell GD. Right-sided hemothorax and recurrent abdominal pain in a 34 year-old woman. Chest. 1993;103:1239. [Medline].

  20. Wilson AL. Endometriosis. A common cause of infertility and pelvic pain. JAAPA. Dec 2003;16(12):20-3. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

endometriosis, pelvic pain, infertility, endometrial implants, endometriosis externa, endometrioma, gynecologic disorder, gynecologic pain, retrograde menstruation, oral contraception, women's health

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Turandot Saul, MD, Staff Physician, Department of Emergency Medicine, Bellevue Hospital Center/New York University Medical Center
Turandot Saul, MD is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Ami K Davé, MD, Assistant Professor, Department of Emergency Medicine, New York University School of Medicine; Assistant Residency Director, Department of Emergency Medicine, New York University/Bellevue Hospital Center
Ami K Davé, MD is a member of the following medical societies: American Association of Physicians of Indian Origin
Disclosure: Nothing to disclose.

Medical Editor

Robert M McNamara, MD, FAAEM, Professor of Emergency Medicine, Temple University; Chief, Department of Internal Medicine, Section of Emergency Medicine, Temple University Hospital
Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Associate Professor, Program Director, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles School of Medicine
Pamela L Dyne, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.