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• W2059606918 abstract "When following current pelvic pain management algorithms, appropriate counseling may lessen emotional and social issues associated with endometriosis-associated pelvic pain. When following current pelvic pain management algorithms, appropriate counseling may lessen emotional and social issues associated with endometriosis-associated pelvic pain. Ballard and colleagues report in this issue of Fertility and Sterility a qualitative interview-based study to investigate possible reasons for a delay in the surgical diagnosis of endometriosis (1Ballard K.D. Lowton K. Wright J.T. What’s the delay? A qualitative study of women’s experiences of reaching a diagnosis of endometriosis.Fertil Steril. 2006; 86: 1296-1301Abstract Full Text Full Text PDF PubMed Scopus (317) Google Scholar). Semistructured face-to-face interviews were conducted with 32 women referred to a hospital pelvic pain clinic in the United Kingdom. At the time of interview, 17 women had been diagnosed with endometriosis and 11 were diagnosed after the interview. The authors do not comment on the timing of diagnosis in four of the patients interviewed. The “total diagnostic delay” ranged from 12 to 324 months. The authors conclude that delays occurred at both the patient and the medical level owing to: 1) “normalization of pain” (i.e., patients told that this is normal discomfort of menses and does not represent pathology) by both the patient and the physician; 2) intermittent hormonal suppression of symptoms; and 3) the use of nondiscriminatory investigation. The authors further state that this study “highlights the importance of an early diagnosis for women who suffer physical, emotional, and social levels when they remain undiagnosed.” The authors’ stated study objectives are “to investigate the reasons women experience delays in the diagnosis of endometriosis and the impact of this.” However, the study design only includes women attending a pelvic pain clinic who had at least a 12-month delay from the onset of symptoms to diagnosis. To appropriately address the stated objectives two comparison groups should be considered. First, the authors should consider studying women who had an “early” surgical diagnosis. It would be interesting to know whether there was something different about their presentation. Did these women “exaggerate” their symptoms, or were their physicians less likely to normalize the patient’s symptoms? Was intermittent hormonal suppression used differently in women who had an early versus late surgical diagnosis? Inclusion of appropriate comparison groups may further our understanding of how symptom normalization led to a delay in diagnosis. A second comparison group of interest would be patients who had a laparoscopy with normal finding. Would these women also speak positively about knowing there was no clear explanation for their pelvic pain, or would the negative findings “be detrimental to a woman’s emotional well-being” (2Moore J. Ziebland S. Kennedy S. People sometimes react funny if they’re not told enough; women’s views about the risks of diagnostic laparoscopy.Health Expectat. 2002; 5: 302-309Crossref PubMed Scopus (23) Google Scholar)? This psychosocial concern and the recognized risks of laparoscopy are important considerations in deciding when to perform surgery for definite diagnosis and perhaps treatment of endometriosis. The authors express concern with nondiscriminatory investigations such as ultrasound. Evidence to date suggests that noninvasive tools (medical history, symptom report, pelvic exam, transvaginal ultrasound, and magnetic resonance imaging) are useful for diagnosis only of ovarian endometriosis (3Eskenazi B. Warner M. Bonsignore L. Olive D. Samuels S. Vercellini P. Validation study of nonsurgical diagnosis of endometriosis.Fertil Steril. 2001; 76: 929-935Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar, 4Moore J. Copley S. Morris J. Lindsell D. Golding S. Kennedy S. A systematic review of the accuracy of ultrasound in the diagnosis of endometriosis.Ultrasound Ostet Gynecol. 2002; 20: 630-634Crossref PubMed Scopus (190) Google Scholar, 5Stratton P. Winkel C. Premkumar A. Chow C. Wilson J. Hearns-Stokes R. et al.Diagnostic accuracy of laparoscopy, magnetic resonance imaging, and histopathlogic examination for detection of endometriosis.Fertil Steril. 2003; 79: 1078-1085Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar). Only one woman with an endometrioma in their study had a “positive” ultrasound. Given the fact that ovarian endometriomas, in the absence of cul-de-sac obliteration, are a prerequisite for a diagnosis of more advanced disease stages, it appears that most of the patients in the study did not have advanced disease. This presumption is in fact contradictory to the authors statement that their study population over-represents “women with more severe disease.” In fact, the stage of disease is never stated in this study. This underscores the need for an appropriate comparison groups to include information on the stage of disease. The authors have attempted to address an important question related to the appropriate management of women with symptoms suggestive of endometriosis. When is it appropriate to normalize symptoms, prescribe medication to suppress symptoms, and use ultrasound to exclude severe endometriotic disease, and when should surgery be performed to obtain a definitive diagnosis and treat the disease? Both the American and the Royal Colleges of Obstetricians and Gynecologists support the use of empirical therapy for endometriosis before laparoscopy in women with pelvic pain (6American College of Obstetricians and GynecologistsMedical management of endometriosis 2006 ACOG Compendium of Selected Publications.Clinical Management Guidelines for Obstetrician-Gynecologists. 1999; 11: 706-718Google Scholar, 7Royal College of Obstetricians and GynaecologistsThe initial management of chronic pelvic pain.Guideline #41. 2005; (April)Google Scholar). One well designed randomized controlled trial suggests that after thorough pretreatment evaluation (including transvaginal ultrasound to identify possible endometriomas) a 3-month course of GnRH agonist is appropriate, because the likelihood of endometriosis being present on post-treatment laparoscopy is 78%–87% (8Ling F. Pelvic Pain Study GroupRandomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis.Obstet Gynecol. 1999; 93: 51-58Crossref PubMed Scopus (221) Google Scholar). In clinical practice, such an approach should always involve a discussion with the patient that the probable diagnosis is indeed endometriosis. The authors provide some evidence to suggest that appropriate counseling may lessen emotional and social issues associated with endometriosis-associated pelvic pain." @default.
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• W2059606918 title "Delayed diagnosis of endometriosis" @default.
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