Diagnosis of Endometriosis

Robert Z. Spaczynski; Antoni J. Duleba

doi:10.1055/s-2003-41326

Seminars in Reproductive Medicine, Table of Contents

Semin Reprod Med 2003; 21(2): 193-208
DOI: 10.1055/s-2003-41326

Diagnosis of Endometriosis

Robert Z. Spaczynski¹ , Antoni J. Duleba²

¹Division of Infertility Reproductive Endocrinology Department of Gynecology Obstetrics, Karol Marcinkowski University of Medical Sciences Poznan, Poland
²Department of Obstetrics Gynecology, Yale University School of Medicine New Haven Connecticut

Abstract

ABSTRACT

Endometriosis is a common disorder of women of reproductive age, yet diagnosis of this condition is often problematic. The most frequent clinical presentations of endometriosis include dysmenorrhea, pelvic pain, dyspareunia, infertility, and pelvic mass. However, the correlation between these symptoms and the stage of endometriosis is poor. Currently available laboratory markers are of limited value. At present, the best marker, serum CA-125, is usually elevated only in advanced stages and therefore not suitable for routine screening. Transvaginal ultrasound and magnetic resonance imaging are often helpful, particularly in detection of endometriotic cysts. Recently, transrectal ultrasound and magnetic resonance imaging were shown to be valuable in detection of deep infiltrating lesions, especially in the rectovaginal septum. Although direct assessment of endometriotic foci at laparoscopy may be viewed as a “gold standard” for identifying endometriosis, the correlation of laparoscopic observations with histological findings is often low. Ultimately, diagnosis of endometriosis requires a careful clinical evaluation in combination with judicious use and critical interpretation of laboratory tests, imaging techniques, and, in most instances, surgical staging combined with histological examination of excised lesions.

KEYWORDS

Endometriosis - laparoscopy - CA-125 - imaging techniques

Full Text

References

REFERENCES

1 Brosens I, Puttemans P, Deprest J. Appearances of endometriosis. Baillieres Clin Obstet Gynaecol . 1993; 7 741-757
2 Strathy J H, Molgaard C A, Coulam C B, Melton L JD. Endometriosis and infertility: a laparoscopic study of endometriosis among fertile and infertile women. Fertil Steril . 1982; 38 667-672
3 Sangi-Haghpeykar H, Poindexter 3rd N A. Epidemiology of endometriosis among parous women. Obstet Gynecol . 1995; 85 983-992
4 Moen M H, Schei B. Epidemiology of endometriosis in a Norwegian county. Acta Obstet Gynecol Scand . 1997; 76 559-562
5 Mahmood T A, Templeton A. Prevalence and genesis of endometriosis. Hum Reprod . 1991; 6 544-549
6 Koninckx P R. Biases in the endometriosis literature. Illustrated by 20 years of endometriosis research in Leuven. Eur J Obstet Gynecol Reprod Biol . 1998; 81 259-271
7 Norwood G E. Sterility and fertility in women with endometriosis. Clin Obstet Gynecol . 1960; 3 456
8 Olive D L, Haney A F. Endometriosis. In: DeCherney AH ed. Reproductive Failure New York: Churchill Livingstone 1986: 153-201
9 Nunley W C, Kitchin J D. Congenital atresia of the uterine cervix with pelvic endometriosis. Arch Surg . 1980; 115 757-758
10 Tang L C, Ngan H Y, Tang M H. Rudimentary uterine horn with adenomyosis and pelvic endometriosis in a 23-year-old girl. J Adolesc Health Care . 1986; 7 265-267
11 Olive D L, Henderson D Y. Endometriosis and mullerian anomalies. Obstet Gynecol . 1987; 69 412-415
12 Ugur M, Turan C, Mungan T. et al . Endometriosis in association with mullerian anomalies. Gynecol Obstet Invest . 1995; 40 261-264
13 Goldstein D P, deCholnoky C, Emans S J, Leventhal J M. Laparoscopy in the diagnosis and management of pelvic pain in adolescents. J Reprod Med . 1980; 24 251-256
14 Chatman D L, Ward A B. Endometriosis in adolescents. J Reprod Med . 1982; 27 156-160
15 Reese K A, Reddy S, Rock J A. Endometriosis in an adolescent population: the Emory experience. J Pediatr Adolesc Gynecol . 1996; 9 125-128
16 Cramer D W, Wilson E, Stillman R J. et al . The relation of endometriosis to menstrual characteristics, smoking, and exercise. JAMA . 1986; 255 1904-1908
17 Matorras R, Rodiquez F, Pijoan J I. et al . Epidemiology of endometriosis in infertile women. Fertil Steril . 1995; 63 34-38
18 Parazzini F, Ferraroni M, Fedele L. et al . Pelvic endometriosis: reproductive and menstrual risk factors at different stages in Lombardy, northern Italy. J Epidemiol Community Health . 1995; 49 61-64
19 Gruppo Italiano plSde. Risk factors for pelvic endometriosis in women with pelvic pain or infertility. Eur J Obstet Gynecol Reprod Biol . 1999; 83 195-199
20 Djursing H, Petersen K, Weberg E. Symptomatic postmenopausal endometriosis. Acta Obstet Gynecol Scand . 1981; 60 529-530
21 Matorras R, Elorriaga M A, Pijoan J I, Ramon O, Rodriguez-Escudero F J. Recurrence of endometriosis in women with bilateral adnexectomy (with or without total hysterectomy) who received hormone replacement therapy. Fertil Steril . 2002; 77 303-308
22 Chinegwundoh F I, Ryan P, Luesley T, Chan S Y. Renal and diaphragmatic endometriosis de novo associated with hormone replacement therapy. J Urol . 1995; 153 380-381
23 Wentz A C. Premenstrual spotting: its association with endometriosis but not luteal phase inadequacy. Fertil Steril . 1980; 33 605-607
24 Signorello L B, Harlow B L, Cramer D W, Spiegelman D, Hill J A. Epidemiologic determinants of endometriosis: a hospital-based case-control study. Ann Epidemiol . 1997; 7 267-741
25 Moen M H. Is a long period without childbirth a risk factor for developing endometriosis?. Hum Reprod . 1991; 6 1404-1407
26 Malinak L R, Buttram Jr C V, Elias S, Simpson J L. Heritage aspects of endometriosis. II. Clinical characteristics of familial endometriosis. Am J Obstet Gynecol . 1980; 137 332-337
27 Simpson J L, Elias S, Malinak L R, Buttram Jr C V. Heritable aspects of endometriosis. I. Genetic studies. Am J Obstet Gynecol . 1980; 137 327-331
28 Kennedy S, Mardon H, Barlow D. Familial endometriosis. J Assist Reprod Genet . 1995; 12 32-34
29 Kennedy S. The genetics of endometriosis. Eur J Obstet Gynecol Reprod Biol . 1999; 82 129-133
30 Kennedy S, Bennett S, Weeks D E. Affected sib-pair analysis in endometriosis. Hum Reprod Update . 2001; 7 411-418
31 Moen M H. Endometriosis in monozygotic twins. Acta Obstet Gynecol Scand . 1994; 73 59-62
32 Hadfield R M, Mardon H J, Barlow D H, Kennedy S H. Endometriosis in monozygotic twins. Fertil Steril . 1997; 68 941-942
33 Woodworth S H, Singh M, Yussman M A. et al . A prospective study on the association between red hair color and endometriosis in infertile patients. Fertil Steril . 1995; 64 651-652
34 Hornstein M D, Thomas P P, Sober A J. et al . Association between endometriosis, dysplastic naevi and history of melanoma in women of reproductive age. Hum Reprod . 1997; 12 143-145
35 Cramer D W, Hornstein M D, Ng W G, Barbieri R L. Endometriosis associated with the N314D mutation of galactose-1-phosphate uridyl transferase (GALT). Mol Hum Reprod . 1996; 2 149-152
36 Georgiou I, Syrrou M, Bouba I. et al . Association of estrogen receptor gene polymorphisms with endometriosis. Fertil Steril . 1999; 72 164-166
37 Nakago S, Hadfield R M, Zondervan K T. et al . Association between endometriosis and N-Acetyl transferase 2 polymorphisms in a UK population. Mol Hum Reprod. 2001; 7 1079-1083
38 Pauerstein C J. Clinical presentation and diagnosis. In: Schenken RS, ed. Endometriosis. Contemporary Concepts in Clinical Management Philadelphia: JB Lippincott 1989: 127-144
39 el-Yahia A W. Laparoscopic evaluation of apparently normal infertile women. Aust NZ J Obstet Gynaecol . 1994; 34 440-442
40 Murphy A A. Clinical aspects of endometriosis. Ann NY Acad Sci . 2002; 955 1-406
41 Kresch A J, Seifer D B, Sachs L B, Barrese I. Laparoscopy in 100 women with chronic pelvic pain. Obstet Gynecol . 1984; 64 672-674
42 Rapkin A J. Adhesions and pelvic pain: a retrospective study. Obstet Gynecol . 1986; 68 13-15
43 Mahmood T A, Templeton A A, Thomson L, Fraser C. Menstrual symptoms in women with pelvic endometriosis. Br J Obstet Gynaecol . 1991; 98 558-563
44 Gruppo Italiano per lo Studio dE. Relationship between stage, site and morphological characteristics of pelvic endometriosis and pain. Hum Reprod . 2001; 16 2668-2671
45 Davis G D, Thillet E, Lindemann J. Clinical characteristics of adolescent endometriosis. J Adolesc Health . 1993; 14 362-368
46 Williams T J, Pratt J H. Endometriosis in 1,000 consecutive celiotomies: incidence and management. Am J Obstet Gynecol . 1977; 129 245-250
47 Vercellini P, Trespidi L, De Giorgi O. et al . Endometriosis and pelvic pain: relation to disease stage and localization. Fertil Steril . 1996; 65 299-304
48 Fedele L, Bianchi S, Bocciolone L, Di Nola G, Parazzini F. Pain symptoms associated with endometriosis. Obstet Gynecol . 1992; 79 767-769
49 Muzii L, Marana R, Pedulla S, Catalano G F, Mancuso S. Correlation between endometriosis-associated dysmenorrhea and the presence of typical or atypical lesions. Fertil Steril . 1997; 68 19-22
50 Fedele L, Parazzini F, Bianchi S, Arcaini L, Candiani G B. Stage and localization of pelvic endometriosis and pain. Fertil Steril . 1990; 53 155-158
51 Perper M M, Nezhat F, Goldstein H, Nezhat C H, Nezhat C. Dysmenorrhea is related to the number of implants in endometriosis patients. Fertil Steril . 1995; 63 500-503
52 Vercellini P, Bocciolone L, Vendola N. et al . Peritoneal endometriosis. Morphologic appearance in women with chronic pelvic pain. J Reprod Med . 1991; 36 533-536
53 Demco L. Mapping the source and character of pain due to endometriosis by patient-assisted laparoscopy. J Am Assoc Gynecol Laparosc . 1998; 5 241-245
54 Muzii L, Marana R, Brunetti L. et al . Atypical endometriosis revisited: clinical and biochemical evaluation of the different forms of superficial implants. Fertil Steril . 2000; 74 739-742
55 Stovall D W, Bowser L M, Archer D F, Guzick D S. Endometriosis-associated pelvic pain: evidence for an association between the stage of disease and a history of chronic pelvic pain. Fertil Steril . 1997; 68 13-18
56 Koninckx P R, Meuleman C, Demeyere S, Lesaffre E, Cornillie F J. Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril . 1991; 55 759-765
57 Porpora M, Koninckx P, Piazze J. et al . Correlation between endometriosis and pelvic pain. J Am Assoc Gynecol Laparosc . 1999; 6 429-434
58 Ranney B. Emergency operations due to hemoperitoneum. Obstet Gynecol . 1970; 36 437-442
59 Rovito P, Gittleman M. Two cases of endometrioma in cesarean scars. Surgery . 1986; 100 118-120
60 Brenner C, Wohlgemuth S. Scar endometriosis. Surg Gynecol Obstet . 1990; 170 538-540
61 Wolf Y, Haddad R, Werbin N, Skornick Y, Kaplan O. Endometriosis in abdominal scars: a diagnostic pitfall. Am Surg . 1996; 62 1042-1044
62 Dwivedi A J, Agrawal S N, Silva Y J. Abdominal wall endometriomas. Dig Dis Sci . 2002; 47 456-461
63 Macafee C H, Greer H L. Intestinal endometriosis: a report of 29 cases and a survey of the literature. J Obstet Gynaecol Br Emp . 1960; 67 539-543
64 Prystowsky J B, Stryker S J, Ujiki G T, Poticha S M. Gastrointestinal endometriosis: incidence and indications for resection. Arch Surg . 1988; 123 855-858
65 Shah M, Tager D, Feller E. Intestinal endometriosis masquerading as common digestive disorders. Arch Intern Med . 1995; 155 977-980
66 Azzena A, Litta P, Ferrara A. et al . Rectosigmoid endometriosis: diagnosis and surgical management. Clin Exp Obstet Gynecol . 1998; 25 94-96
67 Yantiss R K, Clement P B, Young R H. Endometriosis of the intestinal tract: a study of 44 cases of a disease that may cause diverse challenges in clinical and pathologic evaluation. Am J Surg Pathol . 2001; 25 445-454
68 Cravello L, D'Ercole C, Le Treut P Y, Blanc B. Hepatic endometriosis: a case report. Fertil Steril . 1996; 66 657-659
69 Skor A B, Warren M M, Mueller Jr O E. Endometriosis of bladder. Urology . 1977; 9 689-692
70 Sircus S I, Sant G R, Ucci Jr A A. Bladder detrusor endometriosis mimicking interstitial cystitis. Urology . 1988; 32 339-342
71 Donnez J, Spada F, Squifflet J, Nisolle M. Bladder endometriosis must be considered as bladder adenomyosis. Fertil Steril . 2000; 74 1175-1181
72 Donnez J, Nisolle M, Squifflet J. Ureteral endometriosis: a complication of rectovaginal endometriotic (adenomyotic) nodules. Fertil Steril . 2002; 77 32-37
73 Slasky B S, Siewers R D, Lecky J W, Zajko A, Burkholder J A. Catamenial pneumothorax: the roles of diaphragmatic defects and endometriosis. AJR . 1982; 138 639-643
74 Velasco Oses A, Hilario Rodriguez E, Santamaria Garcia L J. et al . Catamenial pneumothorax with pleural endometriosis and hemoptysis. Diagn Gynecol Obstet . 1982; 4 295-299
75 Elliot D L, Barker A F, Dixon L M. Catamenial hemoptysis. New methods of diagnosis and therapy. Chest . 1985; 87 687-688
76 Rychlik D F, Bieber E J. Thoracic endometriosis syndrome resembling pulmonary embolism. J Am Assoc Gynecol Laparosc . 2001; 8 445-448
77 Cooper M J, Russell P, Gallagher P J. Diaphragmatic endometriosis. Med J Aust . 1999; 171 142-143
78 Redwine D B. Diaphragmatic endometriosis: diagnosis, surgical management, and long-term results of treatment. Fertil Steril . 2002; 77 288-296
79 Thibodeau L L, Prioleau G R, Manuelidis E E, Merino M J, Heafner M D. Cerebral endometriosis. Case report. J Neurosurg . 1987; 66 609-610
80 Moeser P, Donofrio P D, Karstaedt N, Bechtold R, Greiss Jr C F. MRI findings of sciatic endometriosis. Clin Imag . 1990; 14 64-66
81 Descamps P, Cottier J P, Barre I. et al . Endometriosis of the sciatic nerve: case report demonstrating the value of MR imaging. Eur J Obstet Gynecol Reprod Biol . 1995; 58 199-202
82 Fedele L, Bianchi S, Raffaelli R, Zanconato G, Zanette G. Phantom endometriosis of the sciatic nerve. Fertil Steril . 1999; 72 727-729
83 Silver M D, Jokl P. Endometriosis of the pelvis presenting as hip pain: a case report. Clin Orthop . 1999; 368 207-211
84 Koninckx P R, Meuleman C, Oosterlynck D, Cornille F J. Diagnosis of deep endometriosis by clinical examination during menstruation and plasma CA-125 concentration. Fertil Steril . 1996; 65 280-287
85 Chapron C, Dubuisson J B, Pansini V. et al . Routine clinical examination is not sufficient for diagnosing and locating deeply infiltrating endometriosis. J Am Assoc Gynecol Laparosc . 2002; 9 115-119
86 Propst A M, Storti K, Barbieri R L. Lateral cervical displacement is associated with endometriosis. Fertil Steril . 1998; 70 568-570
87 Barbieri R L. Stenosis of the external cervical os: an association with endometriosis in women with chronic pelvic pain. Fertil Steril . 1998; 70 571-573
88 Matorras R, Rodriguez F, Pijoan J I. et al . Are there any clinical signs and symptoms that are related to endometriosis in infertile women?. Am J Obstet Gynecol . 1996; 174 620-623
89 Ripps B A, Martin D C. Correlation of focal pelvic tenderness with implant dimension and stage of endometriosis. J Reprod Med . 1992; 37 620-624
90 Eskenazi B, Warner M, Bonsignore L. et al . Validation study of nonsurgical diagnosis of endometriosis. Fertil Steril . 2001; 76 929-935
91 Barbieri R L, Niloff J M, Bast R C. et al . Elevated serum concentration of CA-125 in patients with advanced endometriosis. Fertil Steril . 1986; 45 630-634
92 Pittaway D, Fayez J. The use of Ca-125 in the diagnosis and management of endometriosis. Fertil Steril . 1986; 46 790-795
93 Abu-Musa A, Takahashi K, Nagata H. et al . CA-125 in menstrual discharge in patients with chronic pelvic pain. Int J Gynaecol Obstet . 1992; 37 111-114
94 Koninckx P R, Riittinen L, Seppala M, Cornillie F J. CA-125 and placental protein 14 concentrations in plasma and peritoneal fluid of women with deeply infiltrating pelvic endometriosis. Fertil Steril . 1992; 57 523-530
95 Hornstein M D, Thomas P P, Gleason R E, Barbieri R L. Menstrual cyclicity of CA-125 in patient with endometriosis. Fertil Steril . 1992; 58 279-283
96 O'Shaughnessy A, Check J H, Nowroozi K, Lurie D. CA-125 levels measured in different phases of the menstrual cycle in screening for endometriosis. Obstet Gynecol . 1993; 81 99-103
97 Hornstein M D, Harlow B L, Thomas P P, Check J H. Use of a new CA 125 assay in the diagnosis of endometriosis. Hum Reprod . 1995; 10 932-934
98 Pittaway D E. Assay characteristics of the immunoradiometric method for CA-125. Fertil Steril . 1989; 51 348-350
99 Mol B W, Bayram N, Lijmer J G. et al . The performance of CA-125 measurement in the detection of endometriosis: a meta-analysis. Fertil Steril . 1998; 70 1101-1108
100 Pittaway D E, Fayez J A. Serum CA-125 antigen levels increase during menses. Am J Obstet Gynecol . 1987; 156 75-76
101 Bon G G, Kenemans P, Dekker J J. et al . Fluctuations in CA 125 and CA 15-3 serum concentrations during spontaneous ovulatory cycles. Hum Reprod . 1999; 14 566-570
102 Hompes P G, Koninckx P R, Kennedy S. et al . Serum CA-125 concentrations during midfollicular phase, a clinically useful and reproducible marker in diagnosis of advanced endometriosis. Clin Chem . 1996; 42 1871-1874
103 Pittaway D E, Douglas J W. Serum CA-125 in women with endometriosis and chronic pelvic pain. Fertil Steril . 1989; 51 68-70
104 Cheng Y M, Wang S T, Chou C Y. Serum CA-125 in preoperative patients at high risk for endometriosis. Obstet Gynecol . 2002; 99 375-380
105 Pittaway D E. The use of serial CA 125 concentrations to monitor endometriosis in infertile women. Am J Obstet Gynecol . 1990; 163 1032-1035
106 Pittaway D E, Rondinone D, Miller K A, Barnes K. Clinical evaluation of Ca-125 concentrations as prognostic factor for pregnancy in infertile women with surgically treated endometriosis. Fertil Steril . 1995; 64 321-324
107 Chen F P, Soong Y K, Lee N, Lo S K. The use of serum CA-125 as a marker for endometriosis in patients with dysmenorrhea for monitoring therapy and for recurrence of endometriosis. Acta Obstet Gynecol Scand . 1998; 77 665-670
108 Pittaway D E, Fayez J A, Douglas J W. Serum CA-125 in the evaluation of benign adnexal cysts. Am J Obstet Gynecol . 1987; 157 1426-1428
109 Koninckx P R, Muyldermans M, Moerman P. et al . CA 125 concentrations in ovarian “chocolate” cyst fluid can differentiate an endometriotic cyst from a cystic corpus luteum. Hum Reprod . 1992; 7 1314-1317
110 Muscatello R, Cucinelli F, Fulghesu A. et al . Multiple serum marker assay in the diagnosis of endometriosis. Gynecol Endocrinol . 1992; 6 265-269
111 Molo M W, Kelly M, Radwanska E, Binor Z. Preoperative serum CA-125 and CA-72 in predicting endometriosis in infertility patients. J Reprod Med . 1994; 39 964-966
112 Abrao M S, Podgaec S, Pinotti J A, de Oliveira M R. Tumor markers in endometriosis. Int J Gynaecol Obstet . 1999; 66 19-22
113 Telimaa S, Kauppila A, Rönnberg L, Suikkari A, Seppala M. Elevated serum levels of endometrial secretory protein PP14 in patients with advanced endometriosis: suppression by treatment with danazol and high-dose medroxyprogesterone. Am J Obstet Gynecol . 1989; 161 866-871
114 Medl M, Ogris E, Peters-Engl C. et al . Serum levels of the tumour-associated trypsin inhibitor in patients with endometriosis. Br J Obstet Gynaecol . 1997; 104 78-81
115 Abrao M S, Podgaec S, Filho B M. et al . The use of biochemical markers in the diagnosis of pelvic endometriosis. Hum Reprod . 1997; 12 2523-2527
116 Wild R A, Hirisave V, Bianco A, Podczaski E S, Demers L M. Endometrial antibodies versus CA-125 for the detection of endometriosis. Fertil Steril . 1991; 55 90-94
117 Wild R A, Hirisave V, Podczaski E S. et al . Autoantibodies associated with endometriosis: can their detection predict presence of the disease?. Obstet Gynecol . 1991; 77 927-931
118 Switchenko A C, Kauffman R S, Becker M. Are there antiendometrial antibodies in sera of women with endometriosis?. Fertil Steril . 1991; 56 235-241
119 Fernandez-Shaw S, Kennedy S H, Hicks B R. et al . Anti-endometrial antibodies in women measured by an enzyme-linked immunosorbent assay. Hum Reprod . 1996; 11 1180-1184
120 Friedman H, Vogelzang R L, Mendelson E B, Neiman H L, Cohen M. Endometriosis detection by US with laparoscopic correlation. Radiology . 1985; 157 217-220
121 Alexiadis G, Lambropoulou M, Deftereos S. et al . Abdominal wall endometriosis-ultrasound research: a diagnostic problem. Clin Exp Obstet Gynecol . 2001; 28 121-122
122 Balleyguier C, Chapron C, Dubuisson J B. et al . Comparison of magnetic resonance imaging and transvaginal ultrasonography in diagnosing bladder endometriosis. J Am Assoc Gynecol Laparosc . 2002; 9 15-23
123 Athey P A, Diment D D. The spectrum of sonographic findings in endometriomas. J Ultrasound Med . 1989; 8 487-491
124 Patel M, Feldstein V, Dillon C, Lipson S, Filly R. Endometriomas: diagnostic performance of US. Radiology . 1999; 210 739-745
125 Kurjak A, Kupesic S. Scoring system for prediction of ovarian endometriosis based on transvaginal color and pulsed Doppler sonography. Fertil Steril . 1994; 62 81-88
126 Alcazar J L, Laparte C, Jurado M, Lopez-Garcia G. The role of transvaginal ultrasonography combined with color velocity imaging and pulsed Doppler in the diagnosis of endometrioma. Fertil Steril . 1997; 67 487-491
127 Guerriero S, Ajossa S, Mais V. et al . The diagnosis of endometriomas using colour Doppler energy imaging. Hum Reprod . 1998; 13 1691-1695
128 Pascual M. Role of color Doppler ultrasonography in the diagnosis of endometriotic cyst. J Ultrasound Med . 2000; 19 695-699
129 Alcazar J. Transvaginal colour Doppler in patients with ovarian endometriomas and pelvic pain. Hum Reprod . 2001; 16 2672-2675
130 Hata T, Yanagihara T, Hayashi K. et al . Three-dimensional ultrasonographic evaluation of ovarian tumours: a preliminary study. Hum Reprod . 1999; 14 858-861
131 Kurjak A, Kupesic S, Anic T, Kosuta D. Three-dimensional ultrasound and power Doppler improve the diagnosis of ovarian lesions. Gynecol Oncol . 2000; 76 28-32
132 Fedele L, Bianchi S, Portuese A, Borruto F, Dorta M. Transrectal ultrasonography in the assessment of rectovaginal endometriosis. Obstet Gynecol . 1998; 91 444-448
133 Chapron C, Dumontier I, Dousset B. et al . Results and role of rectal endoscopic ultrasonography for patients with deep pelvic endometriosis. Hum Reprod . 1998; 13 2266-2270
134 Roseau G, Dumontier I, Palazzo L. et al . Rectosigmoid endometriosis: endoscopic ultrasound features and clinical implications. Endoscopy . 2000; 32 525-530
135 Arrive L, Hricak H, Martin M C. Pelvic endometriosis: MR imaging. Radiology . 1989; 171 687-692
136 Zawin M, McCarthy S, Scout L, Comite F. Endometriosis appearance and detection at MRI. Radiology . 1989; 171 693-696
137 Ha H K, Lim Y T, Kim H S. et al . Diagnosis of pelvic endometriosis: fat-suppressed TI-weighted vs conventional MR images. AJR . 1994; 163 127-131
138 Ascher S M, Agrawal R, Bis K G. et al . Endometriosis: appearance and detection with conventional and contrast-enhanced fat-suppressed spin-echo techniques. J Magn Reson Imag . 1995; 5 251-257
139 Nishimura K, Togashi K, Itoh K. et al . Endometrial cysts of the ovary: MR imaging. Radiology . 1987; 162 315-318
140 Bis K, Vrachliotis T, Agrawal R. et al . Pelvic endometriosis: MR imaging spectrum with laparoscopic correlation and diagnostic pitfalls. Radiographics . 1997; 17 639-655
141 Togashi K, Nishimura K, Kimura I. et al . Endometrial cysts: diagnosis with MR imaging. Radiology . 1991; 180 73-78
142 Sugimura K, Okizuka H, Imaoka I. et al . Pelvic endometriosis: detection and diagnosis with chemical shift MR imaging. Radiology . 1993; 188 435-438
143 Zawin M, McCarthy S, Scoutt L. et al . Monitoring therapy with a gonadotropin-releasing hormone analog: utility of MR imaging. Radiology . 1990; 175 503-506
144 Takahashi K, Okada S, Okada M. et al . Magnetic resonance imaging and serum Ca-125 in evaluating patients with endometriomas prior to medical therapy. Fertil Steril . 1996; 65 288-292
145 Sugimura K, Okizuka H, Kaji Y. et al . MRI in predicting the response of ovarian endometriomas to hormone therapy. J Comput Assist Tomogr . 1996; 20 145-150
146 Binkovitz L A, King B F, Ehman R L. Sciatic endometriosis: MR appearance. J Comput Assist Tomogr . 1991; 15 508-510
147 Kinkel K, Chapron C, Balleyguier C. et al . Magnetic resonance imaging characteristics of deep endometriosis. Hum Reprod . 1999; 14 1080-1086
148 Eguchi S, Komuta K, Haraguchi M, Furui J, Kanematsu T. MRI facilitated a diagnosis of endometriosis of the rectum. J Gastroenterol . 2000; 35 784-788
149 Forsgren H, Lindhagen J, Melander S, Wagermark J. Colorectal endometriosis. Acta Chir Scand . 1983; 149 431-435
150 Zanetta G, Webb M J, Segura J W. Ureteral endometriosis diagnosed at ureteroscopy. Obstet Gynecol . 1998; 91 857-859
151 Martin D C, Hubert G D, Vander Zwaag R, el-Zeky F A. Laparoscopic appearances of peritoneal endometriosis. Fertil Steril . 1989; 51 63-67
152 Murphy A A, Guzick D S, Rock J A. Microscopic peritoneal endometriosis. Fertil Steril . 1989; 51 1072-1073
153 Stripling M, Martin D, Chatman D, Vander Zwaag R, Poston W. Subtle appearance of pelvic endometriosis. Fertil Steril . 1988; 49 427-431
154 Jansen R P, Russell P. Nonpigmented endometriosis: clinical, laparoscopic, and pathologic definition. Am J Obstet Gynecol . 1986; 155 1154-1159
155 Nisolle M, Donnez J. Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities. Fertil Steril . 1997; 68 585-596
156 Nisolle M, Paindaveine B, Bourdon A. et al . Histologic study of peritoneal endometriosis in infertile women. Fertil Steril . 1990; 53 984-988
157 Moen M H, Halvorsen T B. Histologic confirmation of endometriosis in different peritoneal lesions. Acta Obstet Gynecol Scand . 1992; 71 337-342
158 Wiegerinck M, Van Dop P, Brosens I. The staging of peritoneal endometriosis by the type of active lesion in addition to the revised American Fertility Society classification. Fertil Steril . 2001; 60 461-464
159 Redwine D B. Age-related evolution in color appearance of endometriosis. Fertil Steril . 1987; 48 1062-1063
160 Murphy A A, Green W R, Bobbie D, dela Cruz C Z, Rock J A. Unsuspected endometriosis documented by scanning electron microscopy in visually normal peritoneum. Fertil Steril . 1986; 46 522-524
161 Balasch J, Creus M, Fabregues F. et al . Visible and non-visible endometriosis at laparoscopy in fertile and infertile women and in patients with chronic pelvic pain: a prospective study. Hum Reprod . 1996; 11 387-391
162 Redwine D B. Peritoneal blood painting: an aid in the diagnosis of endometriosis. Am J Obstet Gynecol . 1989; 161 865-866
163 Gleicher N, Karande V, Rabin D, Dudkiewicz A, Pratt D. The bubble test: a new tool to improve the diagnosis of endometriosis. Hum Reprod . 1995; 10 923-926
164 Walter A J, Hentz J G, Magtibay P M, Cornella J L, Magrina J F. Endometriosis: correlation between histologic and visual findings at laparoscopy. Am J Obstet Gynecol . 2001; 184 1407-1411
165 The American Fertility Society. Revised American Fertility Society classification of endometriosis: 1985. Fertil Steril . 1985; 43 351-352
166 Vercellini P, Vendola N, Bocciolone L. et al . Reliability of the visual diagnosis of ovarian endometriosis. Fertil Steril . 1991; 56 1198-1200
167 Nezhat F, Nezhat C, Allan C, Metzger D, Sears D. Clinical and histologic classification of endometriomas. J Reprod Med . 1992; 37 771-776
168 Candiani G B, Vercellini P, Fedele L. Laparoscopic ovarian puncture for correct staging of endometriosis. Fertil Steril . 1990; 53 994-997
169 Redwine D B. Ovarian endometriosis: a marker for more extensive pelvic and intestinal disease. Fertil Steril . 1999; 72 310-315
170 Brosens I. Endometriosis: a disease because it is characterized by bleeding. Am J Obstet Gynecol . 1997; 176 263-267
171 Donnez J, Nisolle M, Gillerot S. et al . Rectovaginal septum adenomyotic nodules: a series of 500 cases. Br J Obstet Gynaecol . 1997; 104 1014-1018
172 Cornillie F J, Oosterlynck D, Lauweryns J M, Koninckx P R. Deeply infiltrating pelvic endometriosis: histology and clinical significance. Fertil Steril . 1990; 53 978-983
173 Koninckx P R, Martin D C. Deep endometriosis: a consequence of infiltration or retraction or possibly adenomyosis externa?. Fertil Steril . 1992; 58 924-928
174 Simsir A, Thorner K, Waisman J, Cangiarella J. Endometriosis in abdominal scars: a report of three cases diagnosed by fine-needle aspiration biopsy. Am Surg . 2001; 67 984-986
175 Gordts S, Campo R, Brosens I. Office transvaginal hydrolaparoscopy for early diagnosis of pelvic endometriosis and adhesions. J Am Assoc Gynecol Laparosc . 2000; 7 45-49
176 Brosens I, Campo R, Gordts S, Brosens J. An appraisal of the role of laparoscopy: past, present, and future. Int J Gynaecol Obstet . 2001; 74 (suppl 1) S9-S14
177 Patton P, Field C, Harms R, Coulam C. Ca-125 levels in endometriosis. Fertil Steril . 1986; 45 770-773
178 Mais V, Guerriero S, Ajossa S. et al . The efficiency of transvaginal ultrasonography in the diagnosis of endometrioma. Fertil Steril . 1993; 60 776-780
179 Guerriero S, Ajossa S, Paoletti A. et al . Tumor markers and transvaginal ultrasonography in the diagnosis of endometrioma. Obstet Gynecol . 1996; 88 403-407