Key words endometriosis - dysmenorrhea - dyschezia
Introduction
Endometriosis is one of the most common, benign, gynecological disorders, affecting
around 15% of all women of reproductive age, 60% of all women with chronic pelvic
pain and 50% of all infertile women [1 ], [2 ], [3 ]. The incidence in Germany is 40 000 new cases per year; around 80 million women
are affected worldwide [4 ], [5 ], [6 ]. The exact prevalence in the female population in the reproductive years is unknown
as final confirmation is only possible with diagnostic laparoscopy. The most common
sites of endometriosis include the pelvic peritoneum, the ovaries and the rectovaginal
septum [7 ].
Endometriosis is a chronic disease which is associated with regular symptoms, repeated
surgical interventions and lifelong hormone treatment. Long-term effects include chronic
pain and infertility [7 ]. The clinical presentation of the disease is quite varied. Endometriosis may be
asymptomatic and may only be detected as an incidental finding during abdominal surgery.
As the symptoms are unspecific and they often overlap with the symptoms of other gynecological
and gastroenterological disorders, misdiagnoses are common and can include irritable
bowel syndrome or pelvic infection [8 ]. Symptoms typical for endometriosis include dysmenorrhea, pelvic pain, dyspareunia,
dysuria and dyschezia as well as infertility [1 ], [9 ]. The heterogeneity of these symptoms makes it difficult to arrive at the correct
diagnosis, which is often delayed. Despite the high incidence of endometriosis, on
average 10.4 years elapsed between the initial symptoms and the final diagnosis. During
this period, patients were given at least one incorrect diagnosis [10 ]. An international comparison showed similar figures for the interval between initial
symptoms and correct diagnosis; in the USA, an average of 11.7 years elapsed and in
Great Britain, the average was 8.0 years until the correct diagnosis was obtained
[6 ], [9 ], [11 ], [12 ].
How much the patient is aware of the disease depends on the symptoms, when the correct
diagnosis was made, and the patientʼs individual situation [13 ]. Receiving a diagnosis of endometriosis significantly affects the patientʼs health-related
quality of life. The resilience of patients with endometriosis is reduced; on average,
patients are off work 7.41 hours per week [14 ]. In the USA. the cost associated with treating endometriosis including the loss
of working hours amounted to 69 billion dollars in 2009 [15 ], [16 ].
National and international consensus statements have been developed for the diagnosis
and treatment of endometriosis. Non-invasive methods for a diagnostic workup include
imaging procedures, the determination of serum biomarkers, and systematic questioning
of patients about their symptoms [17 ], [18 ]. Out of a cohort of 1200 women who underwent laparoscopy for sterilization, infertility,
pelvic pain or hysterectomy, patients in whom endometriosis was confirmed intraoperatively
were significantly more often likely to have reported dysmenorrhea preoperatively
[19 ]. Symptoms such as dyschezia and dyspareunia can be predictors for deep-infiltrating
endometriosis [20 ]. An insufficient correlation between the extent of symptoms and the extensively
used revised American Society of Reproductive Medicine (rASRM) classification of 1996
is being discussed internationally [21 ].
In this study, the aim was to evaluate the type and duration of endometriosis symptoms,
the process of obtaining a diagnosis, and the relationship between the pattern of
involvement and the symptoms based on a patient cohort from a well-established certified
endometriosis center in Germany. The investigation looked at the clues provided by
symptoms with the aim of improving sensitivity in future when taking patientsʼ medical
history and actively asking patients about their symptoms. When the individual areas
were looked at, the subgroup of infertile patients were examined separately to determine
possible differences in obtaining a diagnosis and the impact on the stage and subsequent
course of disease.
Material and Methods
Study design and patient recruitment
The data of all patients who presented to the Clinic and Polyclinic for Gynecology
and Reproductive Medicine at Jena University Hospital 1/2016 to 12/2017 to undergo
surgery for endometriosis and its symptoms were retrospectively collected (n = 266).
Patients were contacted by telephone and asked to complete and return a questionnaire.
Patients with no histological confirmation of endometriosis were excluded from the
study (n = 5).
Parameters such as age, prior pregnancies and attempts to have children, endometriosis
stage using the rASRM and the ENZIAN classifications and the location of the endometriosis
lesions were obtained from the electronic patient files. Preoperatively, patients
underwent a gynecological examination with transvaginal ultrasound; if there was a
suspicion of deep-infiltrating endometriosis, patients had additional examinations
such as pelvic MRI, rectal endosonography and rectoscopy, cystoscopy, etc. Following
surgery, endometriosis findings were staged ex post using the rASRM and the ENZIAN
classification systems and the patterns of involvement detected intraoperatively.
Surgical care included surgical steps such as cyst extirpation, excision and coagulation
of endometriosis, adhesiolysis, ureterolysis with partial peritonectomy as well as
bladder and bowel procedures, with the goal of completely removing all endometriosis
lesions.
Research ethics approval and patient information and consent
Before starting the study, an application was sent to the ethics committee of Friedrich
Schiller University Jena which approved the study (no. 5237-08/17). All patients gave
their consent to the use of their clinical, anonymized data.
Questionnaire
To collect the data, a questionnaire was developed together with the Institute for
Medical Statistics, Information Technology and Data Science. The questionnaire was
designed to specifically obtain the following parameters: type and duration of symptoms
before surgery, number of doctors consulted until the diagnosis was made, use of painkillers,
how often patients were unable to work because of symptoms. The questionnaire was
developed as part of a doctoral dissertation and was completed by the patients; their
responses recorded in a database.
Statistical analysis
Statistical analysis was carried out using SPSS Version 25 (SPSS Inc., Chicago, IL,
USA). Mean values and standard deviations or frequencies were calculated for continuous
and categorical variables. Differences between mean values of metric variables were
determined using Studentʼs t-test and for categorical variables using Mann-Whitney
U-test or Fisherʼs exact test. The patient population was divided into a group of
patients with infertility (hereinafter referred to as Group 1; n = 76, 41.8%) and
a group of patients without infertility (Group 2; n = 106, 58.2%). Multivariate, linear
and binary regression analysis was used to investigate possible risk factors for the
endometriosis stage or involvement based on preoperative symptoms.
A p-value of ≤ 0.05 was defined as statistically significant.
Results
Descriptive characteristics of the study population
The response rate for entirely completed questionnaires was 79.5% (182/229) ([Fig. 1 ]). A total of 182 patients were treated for histologically confirmed endometriosis
at the Clinic and Polyclinic for Gynecological and Reproductive Medicine of Jena University
Hospital during the observation period and were available for questionnaire-based
evaluation.
Fig. 1 Recruitment of the study population (recruited and contacted patients, n = 266) as
a function of histological confirmation, return of the completed questionnaire (n = 229),
and completeness of study data (n = 182).
41.8% (n = 76) of these patients reported a medical history of infertility. The percentage
of primary diagnoses (71.1 vs. 69.8%, p = 0.871) und diagnoses of recurrence (28.9
vs. 29.2%, p = 1.0) was similarly distributed for both groups. Both patients with
infertility and patients without infertility were diagnosed with endometriosis incidentally
during other abdominal surgical procedures (5.3 vs. 5.7%; p = 1.0). On average, patients
with infertility were significantly younger (32.84 ± 6.18 years) compared to patients
without infertility (35.28 ± 9.75 years) (p = 0.041).
Symptom-related parameters
Patients reported chronic pelvic pain as the most common symptom with 91.8%. In decreasing
order, other reported symptoms were dyspareunia (53.3%), dysmenorrhea (47.3%), dyschezia
(46.7%) and dysuria (24.7%). A group-specific examination of symptoms, summarized
in [Table 1 ], shows that patients without infertility reported dyschezia significantly more often
compared to patients with infertility (53.8 vs. 36.8%, p = 0.035).
Table 1 Endometriosis-specific symptoms reported by the study population; results are presented
as absolute values and percentages.
Symptom-related parameters
Group 1: endometriosis patients with infertility
n = 76
Group 2: endometriosis patients without infertility
n = 106
p-value
Dysmenorrhea
35 (46.1%)
51 (48.1%)
0.08
Pelvic pain
68 (89.5%)
99 (93.4%)
0.42
Dyspareunia
35 (46.1%)
62 (58.5%)
0.10
Dysuria
16 (27.4%)
29 (21.1%)
0.39
Dyschezia
28 (36.8%)
57 (53.8%)
0.03
In addition to dyschezia, patients were asked about the frequency of unspecific, cycle-related
abdominal complaints. Patients in Group 2 reported a feeling of abdominal pressure
(12.3 vs. 1.3%, p = 0.009), diarrhea (31.1 vs. 13.2%, p = 0.005) and constipation
(21.7 vs. 9.2%, p = 0.027) significantly more often than patients in Group 1. No group-specific
distribution was found for hematochezia (14.2 vs. 9.2%, p = 0.36) and flatulence (13.2
vs. 9.2%, p = 0.485).
Another aspect recorded in the questionnaire was the frequency of symptoms. Patients
in Group 2 reported that symptoms occurred regularly significantly more often compared
to patients with infertility (90.6 vs. 77.6%, p = 0.02), with symptoms usually occurring
at monthly intervals (69.8 vs. 65.8%). Both groups of patients reported having to
take time off work because of symptoms, usually in monthly intervals (10.5 vs. 17.9%;
p = 0.159). [Table 2 ] summarizes the distribution of symptom-related parameters.
Table 2 Symptom-related parameters of the study population such as frequency of symptoms,
regular use of painkillers and frequency of having to take time off work; results
are presented as absolute values and percentages.
Symptom-related parameters
Group 1: endometriosis patients with infertility
n = 76
Group 2: endometriosis patients without infertility
n = 106
p-value
Frequency of symptoms
59 (77.6%)
96 (90.6%)
0.020
5 (6.6%)
16 (15.1%)
3 (3.9%)
6 (5.7%)
50 (65.8%)
74 (69.8%)
Regular use of painkillers
50 (65.8%)
84 (79.2%)
0.060
3 (3.9%)
8 (7.5%)
4 (5.3%)
8 (7.5%)
43 (56.6%)
68 (64.2%)
Frequency of having to take time off work
0.203
0 (0%)
1 (0.9%)
6 (7.9%)
17 (16.0%)
2 (2.6%)
1 (0.9%)
Diagnosis-related parameters
In ⅓ of cases in both groups, more than 10 years elapsed between the first emergence
of symptoms and the diagnosis of endometriosis (39.4 vs. 37.5%). Patients who were
also infertile (Group 1) consulted 2.72 (± 1.58) doctors on average until the diagnosis
of endometriosis was made, patients without infertility (Group 2) consulted an average
of 3.08 (± 1.72) different doctors (p = 0.162). Patients in both groups reported a
positive familial history of endometriosis (13.2 vs. 18.9%, p = 0.418). [Table 3 ] summarizes the diagnosis-related parameters.
Table 3 Diagnosis-related parameters of the study population such as time to diagnosis, type
of diagnosis, familial history and number of doctors consulted until the diagnosis
of endometriosis was made; results are presented as absolute values and percentages.
Diagnosis-related parameters
Group 1: endometriosis patients with infertility
n = 76
Group 2: endometriosis patients without infertility n = 106
p-value
Time to diagnosis
0,69
12 (16.9%)
14 (13.5%)
22 (31.0%)
31 (29.8%)
9 (12.7%)
20 (19.2%)
28 (39.4%)
39 (37.5%)
Primary diagnosis
54 (71.1%)
74 (69.8%)
0.87
Diagnosis of recurrence
22 (28.9%)
31 (29.2%)
1.00
Incidental diagnosis
4 (5.3%)
6 (5.7%)
1.00
Positive familial history
10 (13.2%)
20 (18.9%)
0.42
Number of doctors consulted until the diagnosis was made
2.72 ± 1.58
3.08 ± 1.72
0.16
13 (17.1%)
11 (10.4%)
0.24
31 (40.8%)
43 (40.6%)
15 (19.7%)
20 (18.9%)
8 (10.5%)
12 (11.3%)
5 (6.6%)
9 (8.5%)
2 (2.6%)
13 (13.0%)
Endometriosis-related parameters:
There were no group-specific differences in rASRM stage distribution. Of the patients
in Group 1, 26.4% (n = 19) were classified as rASRM stage I, 25% (n = 18) as rASRM
stage II, 19.4% (n = 14) as rASRM stage III and, the most common finding, 29.2% (n = 21)
were classified as rASRM stage IV. The most common classification of patients in Group
2 was rASRM stage I (28.3%, n = 28), followed by rASRM stage II in 22.2% of cases
(n = 22), rASRM stage III in 23.2% (n = 23) and rASRM stage IV in 26.3% (n = 26).
In both groups, the most common classification of patients with deep infiltrating
endometriosis was ENZIAN B (31 vs. 47, p = 0.53). The distribution of stages is shown
below in [Table 4 ].
Table 4 Stage-related parameters of endometriosis involvement in the study population using
the ENZIAN and the rASRM (classification of the American Society for Reproductive
Medicine) classification systems; results are presented as absolute values and percentages.
Endometriosis-related parameters
Group 1: endometriosis patients with infertility
n = 76
Group 2: endometriosis patients without infertility
n = 106
p-value
rASRM score
0.90
19 (26.4%)
28 (26.4%)
18 (25%)
22 (20.6%)
14 (19.4%)
23 (21.7%)
21 (29.2%)
26 (24.5%)
ENZIAN classification
A compartment
11 (14.5%)
11 (10.3%)
1.00
3 (3.9%)
3 (2.8%)
4 (5.3%)
4 (3.8%)
4 (5.3%)
4 (3.8%
B compartment
31 (40.8%)
47 (44.3%)
0.53
5 (6.6%)
13 (12.3%)
18 (23.7%)
24 (22.6%)
8 (10.5%)
10 (9.4%)
C compartment
14 (18.4%)
16 (15.1%)
0.52
6 (7.9%)
7 (6.6%)
5 (6.6%)
3 (2.8%)
3 (3.9%)
6 (5.6%)
1 (1.3%)
1 (0.9%)
1.0
2 (2.6%)
2 (1.8%)
1.0
4 (5.3%)
5 (4.7%)
1.0
2 (2.6%)
6 (5.6%)
0.47
In our patient population, linear multivariate regression analysis showed no significant
increase in the probable risk of higher grade rASRM scores as a function of typical
symptoms such as “dysmenorrhea”, “pelvic pain”, “dyspareunia”, “dysuria”, “dyschezia”
and “infertility”. The results are summarized in [Table 5 ]. When the pattern of involvement was evaluated, the most common location in both
groups of patients was the pelvic peritoneum (43 vs. 60, p = 1.0). Binary regression
analysis showed a significant increase in the probable risk of involvement of the
pelvic peritoneum as a function of the symptoms; according to this analysis, dysmenorrhea
increased the risk 2.3-fold (p = 0.013). The occurrence of dyspareunia decreased the
risk of pelvic peritoneum involvement (odds ratio 0.475, p = 0.037). The results are
summarized in [Table 6 ]. No significant increases in probable risk based on the symptoms “dysmenorrhea”,
“pelvic pain”, “dyspareunia”, “dysuria”, “dyschezia” and “infertility” were detected
for compartments A, B and C of the ENZIAN classification.
Table 5 Results of linear multivariate regression analysis to evaluate risk factors for rASRM
stages of endometriosis involvement as a function of specific symptoms reported by
the study population.
Symptom
Regression coefficient B
SE
p-value
Lower CI
Upper CI
CI = confidence interval, B is the calculated regression coefficient, SE is the standard
error of the regression coefficient.
Dysmenorrhea
0.054
0.180
0.766
− 0.302
0.409
Pelvic pain
0.445
0.324
0.172
− 0.196
1.086
Dyspareunia
− 0.331
0.196
0.094
− 0.719
0.057
Dysuria
− 0.163
0.222
0.464
− 0.600
0.275
Dyschezia
0.294
0.201
0.145
− 0.103
0.691
infertility
0.051
0.184
0.782
− 0.312
0.414
Table 6 Results of binary regression analysis to evaluate risk factors for endometriosis
involvement of the pelvic peritoneum as a function of specific symptoms reported by
the study population.
Symptom
Regression coefficient B
SE
p-value
Odds ratio
Lower CI
Upper CI
CI = confidence interval, B is the calculated regression coefficient, SE is the standard
error of the regression coefficient.
Dysmenorrhea
0.823
0.33
0.013
2.278
1.193
4.348
Pelvic pain
0.249
0.586
0.670
1.283
0.407
4.043
Dyspareunia
− 0.745
0.356
0.037
0.475
0.236
0.954
Dysuria
0.671
0.411
0.103
1.956
0.874
4.376
Dyschezia
− 0.353
0.357
0.322
0.702
0.349
1.414
Infertility
− 0.083
0.331
0.801
0.920
0.481
1.760
In binary regression analysis, the risk probability for involvement of the pelvic
peritoneum for unspecific but cycle-related gastrointestinal symptoms such as dyschezia,
hematochezia, feeling of abdominal pressure, diarrhea, constipation, bloating and
pelvic pain was significantly higher, with a 2.7-fold increase if patients reported
a history of cycle-related diarrhea (odds ratio: 2.707, 95% CI: 1.063 – 6.895, p = 0.037).
Moreover, analysis of these unspecific cycle-related gastrointestinal complaints found
a significant 4.6-fold increase in the risk probability for rectal involvement if
patients reported cycle-related dyschezia (odds ratio: 4.659, 95% CI: 1.132 – 19.186,
p = 0,033).
Fertility-related parameters
There was a high percentage of nulligravida in the group with infertility (53.9%)
compared to Group 2 (46.2%) (p = 0.046). Patients with infertility reported significantly
lower numbers of spontaneous conceptions in previous pregnancies (34.2 vs. 49.1%,
p = 0.05) and a significantly higher number had used ART (31.6 vs. 6.6%, p = 0.001).
Therapy-related parameters
Following surgical excision, the percentage of patients who returned to work was similar
in both groups. The majority of patients had fully returned to work at two months
postoperatively (94.7 vs. 93.4%, p = 0.413). The reported severity of pain measured
using the visual analog pain scale decreased significantly in both groups postoperatively
(from 7.05 to 2.57 vs. 7.37 to 2.28).
The majority of patients in both groups felt that endometriosis impaired their quality
of life (64.5 vs. 78.3%); this was even more pronounced in Group 2 (p = 0.045).
Discussion
This study aimed to evaluate the type and duration of endometriosis complaints in
a patient population which presented to a clinical-scientific endometriosis center.
The study also investigated the effect of the pattern of endometriosis involvement
on specific complaints.
The mean age of the investigated patient population was 34.26 years, and infertility
was reported by 41.8% of cases. Pelvic pain was the most commonly reported symptom
(91.8%). Peterson et al. investigated risk factors for the presence of endometriosis
in 473 patients prior to laparoscopy; the risk probability of detecting endometriosis
intraoperatively increased 3.6-fold if patients reported pelvic pain (OR 3.67, 95%
CI: 2.44 – 5.50) and 2.4-fold if they reported dysmenorrhea (OR 2.46; 95% CI: 1.28 – 4.72).
In addition to specific symptoms such as pelvic pain, dysmenorrhea, dyspareunia, dyschezia
and dysuria, patients with endometriosis also reported unspecific gastrointestinal
complaints [8 ]. A group-specific examination of symptoms showed that patients without infertility
were particularly likely to report dyschezia (p = 0.035) and unspecific, cycle-related
gastrointestinal symptoms such as a feeling of abdominal pressure (p = 0.009), diarrhea
(p = 0.005) and constipation (p = 0.027). The overlap of endometriosis symptoms with
symptoms of gastroenterological disorders made obtaining the correct diagnosis more
difficult, not least because of misdiagnoses, particularly among patients without
infertility. In a study by Seaman et al. which examined 5540 patients with endometriosis,
patients with endometriosis received a diagnosis of irritable bowel syndrome 3.5 times
more often (OR 3.5; 95% CI: 3.1 – 3.9) compared to patients without endometriosis.
The issue of bowel involvement in endometriosis is controversially discussed in the
literature. The majority of endometriosis lesions are in the area of the pelvic peritoneum
in the immediate vicinity of terminal sections of the large intestine. The inflammation-related
irritation and release of prostaglandins could explain the reported disorders of bowel
function [22 ]. Binary regression analysis showed a 2.7-fold increase in the risk probability of
involvement of the pelvic peritoneum as a function of these unspecific cycle-related
gastrointestinal complaints (dyschezia, hematochezia, feeling of abdominal pressure,
diarrhea, constipation, bloating and pelvic pain) if patients had previously reported
cycle-related diarrhea (p = 0.037, odds ratio 2.707, 95% CI: 1.063 – 6.895).
Hudelist et al. showed that patients with endometriosis had a history of at least
one misdiagnosis. In addition to misdiagnoses which can be a consequence of symptoms
which overlap with those of gastroenterological disorders, unspecific complaints also
lead to a delay in obtaining the correct diagnosis [10 ]. Ballard et al. found that in addition to patients being misdiagnosed, symptoms
were played down and/or suppressed by taking oral, hormone-based contraceptives and
that diagnostic tests with a low sensitivity and specificity were often used [23 ]. In almost 40% of cases of the total patient population, more than 10 years passed
(39.4 vs. 37.5%) between experiencing the initial symptoms and obtaining the correct
diagnosis; no differences were found between patients with infertility and patients
without infertility (p = 0.699). Overall, however, the percentage of diagnoses obtained
within the space of less than one year was somewhat higher in the group of patients
with infertility (16.9 vs. 13.5%). With regard to the time to diagnosis, patients
with infertility appear to benefit from the surgical diagnostic workup for infertility.
Hudelist et al. reported a delay of 10.4 years in Germany and Austria in obtaining
the correct diagnosis for 171 patients [10 ]. An international comparison of the time to diagnosis showed that figures ranged
from 11.7 years (USA) to 6.7 years (Norway) [8 ]. Patients regularly report that symptoms have been present for 180 months and that
the time to diagnosis was delayed by 102 months [23 ]. In our patient population, patients consulted 2.93 ± 1.672 doctors on average until
they obtained the final diagnosis. There was no significant difference between groups
of women with and without infertility (2.72 ± 1.58 vs. 3.08 ± 1.72, p = 0.162).
As regards the distribution of rASRM stages, stages I – IV were evenly distributed
(25.8%, 22.0%, 20.3%, 25.8%). However, because of the retrospective study design,
it was not possible to differentiate between endometriosis lesions and endometriosis-related
adhesions. No significant differences in the distribution of rASRM stages were found
between the two groups (p = 0.9). As regards the typical symptoms of dysmenorrhea,
pelvic pain, dyspareunia, dysuria, dyschezia and infertility, linear multivariate
regression analysis found no significant increase in risk probability for higher rASRM
scores. Other studies have already demonstrated a lack of correlation between rASRM
scores and the severity of patientsʼ complaints [21 ]. The strength of the rASRM classification system is the international prevalence
and acceptance of the system and its ease of use [24 ]. It should be noted that this classification system does not take deep infiltrating
endometriosis into account.
Deep infiltration is found in 48% of all endometriosis cases; these findings are associated
with more pronounced symptoms than superficial endometriosis [25 ]. In the patient population studied here, a total of 152 lesions were classified
as deep infiltrating endometriosis using the ENZIAN classification. An ENZIAN B score
was the most common ENZIAN classification in both groups (31 vs. 47, p = 0.53). The
low incidence of uterine adenomyosis in our patient population was due to the difficulty
of histologically confirming uterine adenomyosis without uterine resection and the
low rate of hysterectomies performed in our patient population. Haas et al. studied
194 cases and found that, in contrast to the rASRM score, the ENZIAN classification
showed a correlation with clinical symptoms. Findings in compartment A showed a strong
association with pelvic pain (p = 0.012), findings in compartment C were associated
with gastrointestinal complaints (p = 0.011) [26 ]. In our study, binary regression analysis of cycle-related gastrointestinal complaints
such as dyschezia, hematochezia, feeling of abdominal pressure, diarrhea, constipation,
bloating and pelvic pain showed a significant 4.6-fold increase in the risk probability
for compartment C involvement if patients reported dyschezia (p = 0.033, odds ratio
4.659, 95% CI: 1.132 – 19.186).
Another strength of the ENZIAN classification system is the attribution to a specific
organ or compartment. The most common pattern of involvement for both groups of patients
was the pelvic peritoneum (43 vs. 60, p = 1.0) and the ovaries (34 vs. 45, p = 0.87).
Binary regression analysis showed a significantly increased risk for involvement of
the pelvic peritoneum based on reported symptoms; according to this analysis, dysmenorrhea
increased the risk of pelvic peritoneum involvement 2.3-fold (p = 0.013). The occurrence
of dyspareunia decreased the risk of pelvic peritoneum involvement (odds ratio 0.475,
p = 0.037). Some studies have suggested that deep dyspareunia may be associated with
deep infiltrating endometriosis [27 ].
The heterogeneity of endometriosis symptoms delays the diagnosis and makes obtaining
a correct diagnosis more difficult [28 ]. rASRM scores are not correlated with patientsʼ symptoms. In addition to typical
symptoms such as dysmenorrhea, symptoms such as unspecific cycle-related gastrointestinal
complaints such as diarrhea can be indications pointing to a diagnosis of peritoneal
endometriosis. Such symptoms can be investigated safely and with few complications
early on, using minimally invasive surgery, which could prevent misdiagnoses such
as irritable bowel syndrome. Symptoms such as dyschezia can be an indication of deep
infiltrating endometriosis with involvement of the rectum. Patients with endometriosis
and infertility have a higher percentage of diagnoses made within the space of less
than one year and need to consult fewer doctors on average until they obtain the correct
diagnosis; overall, however there were no differences between the two patient cohorts
which could be useful in clinical practice to improve the diagnostic workup.
Conclusion
In almost 40% of our total patient population, more than 10 years passed between experiencing
the first symptoms to obtaining the correct diagnosis. To reduce the delay in obtaining
a correct diagnosis, physicians should actively ask about typical endometriosis symptoms
and be aware that unspecific cycle-related gastrointestinal complaints in young women
of reproductive age can be indications for endometriosis. Unspecific, cycle-related
gastrointestinal complaints such as diarrhea and dysmenorrhea increase the risk probability
for peritoneal endometriosis. Cycle-related dyschezia increases the risk probability
for rectal endometriosis. The use of diagnostic laparoscopy as a minimally-invasive
diagnostic procedure can reduce the delay in obtaining the correct diagnosis, particularly
if used in combination with targeted taking of the patientʼs history and careful questioning
about symptoms.
