Interpretation
In a 2016 Cochrane systematic review on non-invasive imaging for
endometriosis, it was reported that advanced TVS has a sensitivity of
0.79 (95% CI 0.69-0.89) and a specificity of 0.94 (95% CI 0.88-1.00)
in diagnosing deep endometriosis.15 For deep
endometriosis, MRI has sensitivity 0.94 (95% CI 0.90-0.97) and
specificity of 0.77 (95% CI 0.44-1.00).15 This
translates to MRI being overall more likely to detect deep
endometriosis, but it does so at the expense of a much larger false
positive rate. TVS and MRI are equally effective at diagnosing
endometriomas.15 MRI is also considered a reasonable
option in some centres, given its performance and cultural
considerations, comparable to ultrasound for DE mapping using the IDEA
consensus.7 Despite the studies used in this
systematic review being published in 2015 or earlier, knowledge
translation to the end-users of imaging tests, our patients, remains
limited. Among the survey responders, only just over one-fourth knew
about the possibility of diagnosis via advanced TVS and less than
one-fifth knew about the utility of MRI, and the majority do not believe
that sort of advanced TVS could potentially be offered where they live.
We did not inquire about MRI access as we advocate that ultrasound
should be considered the first-line imaging
modality.16 However, the same obstacles exist with MRI
where an expert radiologist is essential to ensure the correct protocol
and interpretation for endometriosis.17 We believe the
access to endometriosis MRI expertise would match that of advanced TVS.
Online sources are commonly used by people with endometriosis for
information about various aspects related to their condition; however
their healthcare providers’ knowledge level may also be a relevant
factor contributing to the general population knowledge level. In an
international survey of gynaecologists, a minority of respondents used
advanced TVS or MRI to evaluate patients with suspected endometriosis,
and, in some regions, the availability of advanced TVS is potentially as
low as 14%.18 As such, we may suspect that
gynaecologists are not teaching their patients, either passively or
actively, about advanced techniques to diagnose non-invasively. The
reason behind that phenomenon is likely to be multifactorial, relating
to system differences such as healthcare funding models (e.g. private
versus public), training in gynaecological
ultrasound19, who is performing/interpreting imaging
tests (i.e. sonographer versus radiologist versus gynaecologist), and
national clinical practice guidelines.
Demographics likely play an important role in the diagnostic process.
Bougie et al . noted significant differences in the likelihood of
an endometriosis diagnosis based on race and
ethnicity.20 Another factor might be education, which
is, of course, intimately related to race, ethnicity, and other
socioeconomic factors. In our study, the majority of respondents
(68.2%) had post-secondary education. We found no difference in the
proportion of post-secondary education in those with a surgical
diagnosis compared to those without. However, it is possible that the
overall high levels of education of the patients may have helped to more
effectively navigate complicated healthcare systems and advocate for
themselves to reach surgery (for diagnostic or therapeutic purposes) in
their care pathway. Even in this highly educated cohort, 54.0% learned
something from the content within the survey. With internet resources
considered the primary source of information, this demonstrates the
potential role of open web-based educational platforms. As this study
only investigated country of residence, with a majority of responses
from racially and ethnically diverse countries such as Australia, United
Kingdom, Canada, and the United States of America, we cannot exactly
comment on racial or ethnic differences. However, the diagnostic and
care pathway for patients of various racial and ethnic backgrounds
warrants study.
The approach to diagnosing endometriosis is
changing.21 While diagnostic laparoscopy is often
used, it is used less as a diagnostic procedure and more when surgical
treatment is indicated.22 However, this is problematic
because it leaves individuals undiagnosed unless they fit
surgical indications. Moreover, without using preoperative diagnostic
tools, there is a chance a diagnostic laparoscopy with planned treatment
may be incomplete or abandoned due to surprisingly advanced
disease.23 Advanced imaging could represent a
breakthrough in the former two-step approach of diagnostic and treatment
laparoscopies, highly reducing the risks and the cost of care for
patients.24
It would be essential to consider that, in the opinion of the vast
majority of the respondents, the internet and the gynaecologist would be
the chosen sources to acquire further knowledge on endometriosis.
However, there is evidence that might be significant impairment in the
quality and credibility of the internet’s information related to
endometriosis and other gynaecological
conditions.25–27 We cannot not emphasise enough the
importance of continuous education programmes of health care
professionals and gynaecologists to increase the availability of recent
advancements of diagnostic tools for endometriosis.28