This document discusses various modalities used to investigate endometriosis, including serum markers, imaging, and laparoscopy. It provides details on CA-125 serum markers and various imaging techniques like ultrasound, MRI, CT, and color Doppler. Transvaginal ultrasound is highlighted as the most useful imaging method. Laparoscopy is described as the gold standard for diagnosing endometriosis and allows visualization of different types of endometriotic lesions. Histologic examination of biopsied tissue during laparoscopy provides confirmation of endometriosis.

1. INVESTIGATIONS
FOR
ENDOMETRIOSIS
Devika Venu
Final year MBBS
Madras Medical College

2. VARIOUS MODALITIES

3. SERUM MARKERS

4. SERUM CA-125
>35 U/ml in 80% cases
Recognised by monoclonal antibody assay
Specificity – 80%
Sensitivity – 20-50%
Predict recurrance after therapy

6. IMAGING

7. •Ultra sonography
•MRI
•CT
•Color Doppler

8. ULTRA SONOGRAPHY

9. ULTRASONOGRAPHIC
FEATURES
Diverse features
Usually present as cystic swellings with
DIFFUSE LOW LEVEL ECHOES &
ECHOGENIC WALL FOCI
Occasionally endometriotic cysts may
show septations , thickened walls & wall
nodularity

10. TRANSVAGINAL
• High frequency probe ( 6 - 7.5 MHz )

11. Trans vaginal ultrasound image of a typical
endometrioma. The content is homogeneous and
composed of low-level echoes and the cyst wall is
regular and smooth.

12. Deep endometriosis with bowel involvement :
presence of hypo echoic mass with recto sigmoid
involvement characterised by thin band like echoes
departing from the centre of the mass the so called
“INDIAN HEAD DRESS SIGN”

13. In this case next to the endometriotic nodule
protuding in the bladder, another nodule can be seen
in the pouch between uterus/cervix and the bladder

14. TRANS ABDOMINAL
•Abdominal wall & bladder endometriosis

15. Sagittal trans abdominal pelvic ultrasound: an irregular
hypoechoic mass situated anterior to uterus
invaginating the urinary bladder

16. TRANSRECTAL
• Deep infiltrating endometriosis
• 6.5MHz ,bi convex probe

17. Endometriotic infiltrating lesion in the intestinal wall

18. OTHER TECHNIQUES
SONOVAGINOGRAPHY
• TVS +saline solution in the vagina
• Acoustic window b/w the trans vaginal
probe &the surrounding structure of
vagina
• Increased specificity and sensitivity for
identifying recto vaginal endometriosis

20. ENDOSCOPIC TRANS RECTAL ULTRA
SONOGRAPHY
Intestinal wall infiltration
7.5 -12 MHz radial probe
Allows circumferential images of the
rectum &surrounding areas

21. Rectal wall involvement by deep pelvic
endometriosis

22. 3D ULTRASONOGRAPHY
May allow better visualization of the topography of the
surface & internal echoes as well as the vasculature

23. MRI
Adjunctive non invasive examination
useful in a pre selected high risk
population
Occasionally helpful in visualising solid
endometrial implants & adhesions

24. Identification of endometriosis by MRI relies on
detection of pigmented hemorrhagic lesion.
Endometriomas have a relatively homogeneous high
signal intensity on TI-weighted images because of
degenerated blood products, including
methemoglobin and deoxyhemoglobin.
A characteristic feature of an endometrioma is
"shading" -- hypointense signal on T2-weighted
images.
Signal characteristics vary according to the age of
hemorrhage, and endometriomas may have a mixed
spectrum of appearances

25. Sagittal T2 weighted image demonstrating
endometriosis infiltrating rectum and
bladder

26. COLOR DOPPLER
Blood flow in endometriomas is usually pericystic , especially
noticeable in the hilar region, and usually visualized in regularly
spaced vessels.

27. CT
• Can detect lesions in pleura,brain & other
uncommon sites

28. • Barium enema : double contrast
bowel infiltration
• Intra venous pyelography
• Cystoscopy bladder/ureteral
• urteroscopy involvement

29. DIAGNOSTIC
LAPAROSCOPY

31. • GOLD STANDARD IN THE DIAGNOSIS OF
ENDOMETRIOSIS
• Findings vary with : Duration
Size
Location
• 3 different forms of endometriosis must be
considered during laparoscopic examination
-peritoneal implants
-endometriomas
-DIE

32. 1.PERITONEAL IMPLANTS
Most common in uterosacral ligament, cul-de-sac,
ovarian fossa & adjacent pelvic side walls
Classical : bluish black powder burn lesions
Red flame shaped: highly vascular,early lesion
White fibrous : less vascular healed/latent lesions
Black lesions : advanced
Yellow brown peritoneal patches
Circular peritoneal defects
Adhesions

39. Dense adhesions

40. NEWER TECHNIQUES
Peritoneal blood painting
Bubble test: - infusion of crystalloid into
the cul-de-sac
- to detect subtle lesions

41. 2.ENDOMETRIOMAS
Smooth walled dark , brownish cysts
strongly assossiated with adhesions

42. 3.DEEP INFILTRATING
ENDOMETRIOSIS
Common sites: recto vaginal,
uterovesicular septum,muscular wall of
pelvic structures & uterosacral ligaments
>5mm beneath the peritoneal surface

44. TRANS VAGINAL
HYDROLAPAROSCOPY
Needle cannula system inserted into the posterior
fornix
Injection of saline peritoneal distention
Office screening technique for infertile women
More accurate

45. HISTOLOGIC
CONFIRMATION

46. • Biopsy has to be taken during laparoscopy
and send for histopathologic confirmation

47. THANK YOU