Is Laparoscopy the Gold Standard for the Diagnosis of Endometriosis?

Is Laparoscopy the Gold Standard for the Diagnosis of Endometriosis?
By I.A. Brosens(a) and J.J. Brosens(b)

(a) Leuven Institute for Fertility and Embryology, Leuven, Belgium
(b) Department of Reproductive Sciences and Medicine, Division of Paediatrics, Obstetrics and Gynaecology, ICSM at Hammersmith Hospital, London, UK
* Corresponding author. Tel.: +32-16-270190; fax: +32-16-270197. E-mail address mailto:%20ivo.brosens@med.kuleuven.ac.be

For several decades laparoscopy has been the gold standard for the diagnosis of endometriosis. Indeed, the definition of endometriosis was created by the reflux concept of Sampson's (1) and consequently, visualization of hemorrhagic implants and, as final proof, biopsies showing glands and stroma have been the basis of the diagnosis. Today, there are major reasons to state that the definition and consequently the place of laparoscopy in the diagnosis should undergo a major revision.

First, the definition of endometriosis is based on the reflux concept and not on the original observation of specific endometrial activity at ectopic sites. Indeed, Sampson (2) discovered endometriosis by observing menstrual shedding in endometrial-like, tissue in ovarian chocolate cysts in two patients operated at the time of menstruation.

Secondly, the visual, mechanistic definition neglects to include the smooth muscle cell hyperplasia, which was accurately described by CuIlen (3) to occur along the Müllerian tract, primarily in the myometrium, the posterior fornix, the uterosacral ligaments and to some extent at other fibromuscular sites. It is now well recognized that smooth muscle differentiation is also a specific activity associated with basal endometrium. The present confusing terminology of deep, infiltrating and invasive endometriosis has been a consequence of restricting a disease process to a concept, which neglects the metaplastic changes of mesenchymal cells differentiating into smooth muscle cells (4). The so called deep, rectovaginal endometriosis in contrast with peritoneal and ovarian endometriosis does not correspond with the phenotype of superficial, but basal endometrium and presents all the morphological features of adenomyosis (5,6).

It is therefore logical to redefine endometriosis by the specific, functional changes associated with ectopic endometrial-like tissue. Regardless of the underlying etiology and pathogenesis, the phenotype of ectopic endometrial-like tissue is apparently determined by the surrounding microenvironment (7). Peritoneal and ovarian endometriosis have characteristics, albeit defective, of superficial endometrium and are functionally characterized by sex steroid hormone-dependent bleeding. in contrast, rectovaginal endometriosis, like diffuse uterine adenomyosis is similarly as basal endometrium characterized by inordinate smooth muscle differentiation and hyperplasia and nodule formation.

Moreover, there is increasing evidence that endometriosis is part of a pleiotropic reproductive disorder including aberrant eutopic endometrium, disruption of normal inner myometrial peristalsis, proinflammatory state of the peritoneum, abnormal ovarian steroidogenesis and impaired oocyte maturation (8). The normal sex steroid hormone response of the Müllerian tract is disrupted and the presence of endometriotic implants is only one aspect of the pleiotropic reproductive disorder. Consequently, if the visual concept of endometriosis is being replaced by a functional definition, the method of diagnosis should also undergo a major revision.

There are also clinical reasons to review the place of traditional laparoscopy in the diagnosis of endometriosis. Whilst not classified as major surgery, laparoscopy is an invasive and expensive procedure. It requires general anesthesia of the patient and full operating theatre facilities. The transabdominal approach is responsible for approximately 50% of the complications (9,10). Injury to a major blood vessel can be catastrophic with a reported mortality of 15% and the offending instrument is the Veress needle as often as the trocar (11). The diagnosis of endometriosis by laparoscopy has therefore never been practical. The delay in the diagnosis of endometriosis in patients with infertility and chronic pelvic pain Is 3.5 and 11.7 years respectively (12). The delay results in disease progression with increased risk of persistent disease and patient's anxiety and depression. Monitoring the evolution of the disease by laparoscopy has also not been routine practice. On the contrary, the role of purely diagnostic laparoscopy is being gradually eliminated from the contemporary management of endometriosis, in which suspected lesions are treated surgically when they are first seen. A recent Canadian study showed that this approach results in a modest increase in subsequent pregnancy rates (13). The results of the study remain controversial, but the most consistent finding in similar studies is that destroying visible implants fails to cure the disease.

Therefore, there are major reasons to revise the diagnostic approach of endometriosis. Alternatives to standard laparoscopy for the diagnosis of endometriosis have already been proposed or are in development. Recently, a new office procedure based on the transvaginal access and the use of saline as distension medium, called transvaginal hydrolaparoscopy (THL), has been proposed as a more suitable screening method for early diagnosis of endometriosis in patients with infertility or chronic pelvic pain (14). The safety factors include the use of local anesthesia. transvaginal access, needle technique and saline for distension. The systematic use of saline for distension makes THL a much more sensitive technique for the diagnosis of adhesions. For instance, examination of the ovaries by THL in patients with mild endometriosis revealed 50% more periovarian adhesions compared to standard laparoscopy (15). In addition, THL is likely to restore the normal decision making process of a surgical procedure which proceeds from diagnosis to evaluation of the treatment options with the patient and ultimately a planned surgical procedure. Conventional T2-weighed MR imaging, on the other hand, is an accurate technique to detect adenomyotic hyperplasia in the myometrium. posterior fornix and uterine ligaments (16). This imaging technique can also detect hemorrhagic lesions if greater than 4 mm (17). The development of ultrasensitive endocavitary uterine and rectal MR receiver coils is likely to facilitate detection of early lesions along the Müllerian tract. The technique is noninvasive, is more cost effective than laparoscopy, and can be repeated when indicated.

In conclusion, not only the definition, but also the diagnosis of endometriosis should undergo a major revision. Pelvic endoscopy remains a useful technique to visualize and document the superficial, hemorrhagic type of endometriosis and adhesions, but fails to reveal the adenomyostic, nodular type and, even more important, the pleiotropic reproductive abnormalities. If the visual concept of endometriosis is no longer tenable and endometriosis is apparently part of a pleiotropic reproductive disorder, characterized by disruption of normal sex steroid hormone dependent differentiation process in the Müllerian tract, it is more likely that in the near future a combination of techniques is desirable for the diagnosis of the disease endometriosis/adenomyosis.

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