Diagnosing Endometriosis, Dr. Mark Perloe

Any complaint related to menses suggests endometriosis. Endometriosis associated with the classic symptoms of painful menstrual periods and/or painful sexual intercourse is relatively easy to diagnose. However, when the symptoms are less suggestive-unexplained infertility, irregular periods, or spotting, for example-identifying the disease may be more difficult. Occasionally while doing the pelvic examination I can feel the telltale beading on the outside of the reproductive organs. The only definitive diagnostic procedure for endometriosis, however, is a direct look inside the abdominal cavity and a biopsy of the tissue.

Diagnostic Laparoscopy
Since laparoscopy requires general anesthesia, I try to rule out all other male and female fertility factors before performing it. Depending on the woman's age, history, and findings from the workup, however, I may choose a more aggressive diagnostic approach for a particular couple. If the woman is in her thirties and if she complains of pelvic pain or has unexplained infertility, I'm likely to perform a laparoscopy sooner.
Viewed through the laparoscope, the endometrial lesions look like raised shaggy brown or blue-black areas ranging from 2 to 10 cm (1 to 4 inches) in diameter. If the disease has been present for a prolonged period of time, the tissue adjacent to the implants will pucker and burned-out areas will show fibrotic scars. Advanced endometriosis (stage III or IV) may invade, pucker, and erode the walls of affected organs, and adhesions may be so dense that they "freeze" the pelvic organs into distorted positions.
Dr. Redwine has described the progressive nature of endometriosis lesions. They are first seen as clear vesicles, then become red, and then progress to black lesions over a period of 7-10 years. Dr. Karnaky described water blister lesions becoming blue dome cysts over a period of 4-10 years. The clear lesions are seen are at an average age of 21.5 while black scarred lesions are seen at a mean age of 31.9. This progression from clear to red to black lesions with age confirms the progressive nature of this disease if left untreated. Disease will progress in 47-64% of women without therapy and approximately 20% of women with therapy.
While performing the laparoscopy, I'll force a colored dye through the cervix, uterus, and tubes to demonstrate tubal patency. Many times, the dye will flow through only one tube (preferential flow) because that tube provides the least resistance to the colored liquid. Although this does not mean that the other tube is blocked, it does not rule out that possibility, either.
There is poor correlation between the degree of pain or infertility and the severity of disease. Early lesions which are clear or red are metabolically more active than older, dark, fibrotic lesions. This metabolic activity may be responsible for the associated infertility, immune abnormalities, urinary urgency, pelvic pain or diarrhea.