Endometriosis: A multimodal imaging review

Bowel endometriosis: Surgical customization is demanding

Bowel endometriosis is the most common form of severe deep endometriosis. Surgery is an option in case of infertility and/or chronic pain or in the presence of a stenotic lesion. Clinical examination and preoperative imaging must provide an identity card of the lesion so that customized surgery can be proposed. The primary objective of this tailor-made surgery will always be to preserve the organ. The surgeon then has three options: shaving, discoid resection and segmental resection. The more extensive the resection, the greater the risk of severe short- and long-term complications. Surgery must therefore be adapted to the patient's specific situation and needs. Moreover, personalized care must extend beyond surgery. It must begin before the operation, preparing the patient for the operation like an athlete before a race, and continue afterwards by adapting the follow-up to the surgery performed.

Endometriosis MRI: Atypical cases, pitfalls and mimics

Endometriosis is a common but often underdiagnosed chronic gynaecological disease. Endometriosis mimics other diagnoses both clinically and radiographically, presenting a diagnostic challenge. Endometriosis can be categorised as superficial pelvic endometriosis, deep invasive endometriosis (DIE) or endometrioma. Endometrioma and DIE, including polypoid endometriosis, can masquerade as invasive neoplasms. Endometriosis can be misdiagnosed in less common locations or during pregnancy. Ultrasound is the initial investigation for endometriosis; however, MRI is advantageous in providing a larger field of view for increased detection of nodules as well as distinguishing malignancy with greater certainty. This review highlights endometriosis mimics, pitfalls and atypical cases on MRI.

Giant endometrioma in an asymptomatic patient

Endometriosis is a chronic inflammatory gynecologic disorder characterized by the presence of endometrial-like tissue, including endometrial glands and stroma, outside of the uterine cavity. It is a prevalent condition worldwide, affecting approximately 10% of reproductive-age women and up to 50% of infertile women. Endometriosis manifests in three ways: superficial peritoneal endometriosis, deep infiltrative endometriosis, and ovarian endometriomas, with the possibility of coexistence among them. The disease presents with a range of symptoms, including chronic pelvic pain, dysmenorrhea, dyspareunia, and infertility. Additionally, patients may experience nongynecological symptoms such as dyschezia, dysuria, hematuria, flank pain, and fatigue, among others. The ovaries are the most affected site in endometriosis, typically with cysts measuring less than 6 cm in diameter. Therefore, even in the presence of a large ovarian cyst or in asymptomatic patients, the consideration of an endometrial cyst should not be overlooked.

Association Between Composite Dietary Antioxidant Index and the Risk of Endometriosis-Related Rheumatoid Arthritis in Women of Childbearing Age: A Cross-Sectional Study Based on the National Health and Nutrition Examination Survey Database

Purpose

To evaluate the association between Composite Dietary Antioxidant Index (CDAI) and the risk of endometriosis (EM)-related rheumatoid arthritis (RA) in women of childbearing age.

Methods

Using the data from the National Health and Nutrition Examination Survey database, this cross-sectional study included women of childbearing age. The CDAI was obtained by summing the standardized Z-values of the dietary intakes. EM was diagnosed based on a questionnaire-based survey. The outcome of this study was the presence of RA, which was defined by a questionnaire. The associations of CDAI and EM with the risk of RA were determined using weighted logistic analysis. Additive interaction was evaluated using the relative excess risk due to interaction (RERI), the attributable proportion due to interaction (AP), and the synergy index (S).

Results

In total, 3803 patients were included, of which 74 patients (1.99%) were with RA. A lower CDAI [odds ratio (OR): 1.85, 95% confidence interval (CI): 1.12 to 3.04, P= 0.015] and the presence of EM (OR: 3.05, 95% CI: 1.19 to 7.81, P= 0.023) was associated with the risk of RA. The result demonstrated an additive interaction of a lower CDAI and the presence of EM on the risk of RA (OR: 6.19, 95% CI: 2.33 to 16.43, P <0.001, P of trend =0.007). Nevertheless, there was no significant additive interaction after being assessed by the RERI, AP, and S. However, a joint effect of a lower CDAI and EM on the risk of RA (OR: 3.94, 95% CI: 1.35 to 11.51, P= 0.013) was observed.

Conclusion

Our study identified EM, and lower CDAI, was related to the risk of RA. Lower CDAI score was also associated with the risk of EM-related RA. This study indicates the importance of antioxidant intake in daily diet for the management of EM-related RA.

A Comprehensive Review of the Diagnostic Landscape of Endometriosis: Assessing Tools, Uncovering Strengths, and Acknowledging Limitations

Endometriosis is a prevalent yet often underdiagnosed condition characterized by the presence of endometrial-like tissue outside the uterus, leading to significant morbidity and impaired quality of life. A timely and accurate diagnosis of endometriosis is essential for effective management and improved patient outcomes. This review provides a comprehensive overview of the current diagnostic landscape of endometriosis, including clinical evaluation, imaging modalities, biomarkers, and laparoscopy. The strengths and limitations of each diagnostic approach are critically evaluated, alongside challenges such as delayed diagnosis and misinterpretation of findings. The review emphasizes the importance of multidisciplinary collaboration, standardized diagnostic protocols, and ongoing research to enhance diagnostic accuracy and facilitate early intervention. By addressing these challenges and leveraging emerging technologies, healthcare professionals can improve the diagnosis and management of endometriosis, ultimately enhancing the well-being of affected individuals.

Role of ultrasonography in the diagnosis of endometriosis in infertile women: Ovarian endometrioma, deep endometriosis, and superficial endometriosis

Endometriosis is a complex chronic inflammatory process characterised by the presence of endometrial-like glandular tissue outside the uterine cavity, typically within the pelvic structures. This condition affects up to 10-15 % of women and those assigned female at birth, and can result in chronic pelvic pain and in/subfertility. Treatment goals include medical, surgical options and alternative therapies. Transvaginal ultrasound (TVUS) is the currently recommended first line investigation for endometriosis with magnetic resonance imaging (MRI) reserved for those with equivocal ultrasound findings. In this paper, we aim to outline the commonly seen sonographic appearances of endometriosis divided into anterior, middle and posterior pelvic compartments. Limitations to ultrasound imaging include high operator dependence and patient factors. New imaging techniques and research into the utility of artificial intelligence (AI) into the detection of endometriosis is currently underway, with possibility of reduced diagnostic delay and better patient outcomes.

The definition, diagnosis, and symptoms of the uterine niche - A systematic review

Of all neonates, 21% are delivered by cesarean section (CS). A long-term maternal complication of an SC is a uterine niche. The aim of this review is to provide an overview of the current literature on imaging techniques and niche-related symptomatology. We performed systematic searches on imaging and niche symptoms. For both searches, 87 new studies were included. Niche evaluation by transvaginal sonography (TVS) or contrast sonohysterography (SHG) proved superior over hysteroscopy or magnetic resonance imaging. Studies that used SHG in a random population identified a niche prevalence of 42%-84%. Niche prevalence differed based on niche definition, symptomatology, and imaging technique. Most studies reported an association with gynecological symptoms, poor reproductive outcomes, obstetrical complications, and reduced quality of life. In conclusion, non-invasive TVS and SHG are the superior imaging modalities to diagnose a niche. Niches are prevalent and strongly associated with gynecological symptoms and poor reproductive outcomes.

Feasibility of periprocedural decision on the administration of intravenous contrast media in MRI for endometriosis

PURPOSE

To assess the feasibility of a periprocedural decision on the administration of intravenous contrast media in MRI for endometriosis and to evaluate the frequency and reasons of contrast administrations, the corresponding MRI diagnoses, and outcome.

METHODS

In this retrospective, descriptive cross-sectional single-center study all patients were included, who received a pelvic MRI for evaluation of endometriosis between April 2021 and February 2023. Frequency and reasons of optional intravenous administration of contrast media, corresponding MRI diagnoses and clinical outcome data were noted after re-review of all images, review of radiology reports and review of patients' medical records. The decision on the administration of intravenous contrast media had been made by experienced radiologists, depending on the findings of the non-contrast sequences and the presence of ancillary questions.

RESULTS

303 consecutive patients (mean age, 33.4 years +/- 8.3 [standard deviation]) were evaluated. Periprocedural decision on the administration of intravenous contrast media had been made in all cases. For 219/303 (72.3%) patients, it was decided after review of the non-contrast sequences and exclusion of ancillary questions that contrast administration was not required. 84/303 (27.7%) patients received contrast media, and the most frequent reasons were indeterminate ovarian lesion (41/84 cases, 48.8%) or suspicion of pelvic venous congestion syndrome (26/84 cases, 31.0%). No relevant differences in patient outcomes could be noted (non-contrast/contrast MRI).

CONCLUSIONS

A periprocedural decision on the administration of contrast media in MRI for endometriosis is feasible with little effort. It allows the administration of contrast media to be avoided in most cases. If the administration of contrast media is deemed necessary, repeat examinations can be avoided.