BackTable / OBGYN / Podcast / Episode #30
Ambulatory Workup of Endometriosis Patients
with Dr. Ted Lee
In this episode, Dr. Mark Hoffman invites Dr. Ted Lee, an OBGYN specializing in MIGS and professor of OBGYN at University of Pittsburgh Medical Center, about the ambulatory workup of endometriosis patients.
BackTable, LLC (Producer). (2023, August 17). Ep. 30 – Ambulatory Workup of Endometriosis Patients [Audio podcast]. Retrieved from https://www.backtable.com
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Dr. Ted Lee
Dr. Ted Lee is a clinical professor and director of minimally invasive gynecologic surgery at Magee Womens Hospital of UPMC in Pittsburgh, Pennsylvania.
Dr. Mark Hoffman
Dr. Mark Hoffman is an OBGYN and minimally invasive gynecologic surgeon with University of Kentucky Healthcare.
The episode begins with the physicians discussing the difficulties of diagnosing endometriosis, including: the stigma of pelvic pain/not believing women’s pain, recognition that pelvic pain is not normal, the discomfort of physicians asking the appropriate questions for pelvic pain, and the hesitancy towards surgery by physicians and patients all play a role. Many patients have been having pain for years that may have been covered up by OCP use or misdiagnosed as IBS or interstitial cystitis.
Ted emphasizes the importance of a thorough history in diagnosing endometriosis. Essential information includes age of onset of symptoms, gravidity and parity, prior C-section (abdominal wall endometriosis) and the “3 D’s” of dyspareunia, dyschezia, and most importantly dysmenorrhea. A quality physical exam can also elucidate endometriosis. Ted starts by palpating the anterior vaginal wall, then the levator ani muscles and cervix, and finally the rectovaginal exam. Palpation of the uterosacral ligament and posterior cul-de-sac in endometriosis patients causes a visceral reaction, and advanced disease may also have nodules felt. The majority of patients don’t require additional imaging since ultrasound is insensitive for stage 1 and 2 endometriosis. Indications for MRI include endometrioma, nodularities felt on exam, and abdominal wall endometriosis. When it comes to surgery, both doctors emphasize the importance of having other surgeons on your team, including colorectal surgery, general surgery, and urology. Ted dives into some surgical tips and techniques from his years of experience.
Finally, the physicians end by discussing the future of endometriosis diagnosis. A Japanese study has recently found fusobacterium in the uterine microbiome in endometriosis patients more often than those without. Also, a French study has taken saliva samples and found signature microRNAs for endometriosis. It will be interesting to see how studies like these change the future of endometriosis diagnosis and if it will bring new challenges, such as overtreatment and overdiagnosis.
Muraoka, A., Suzuki, M., Hamaguchi, T., Watanabe, S., Iijima, K., Murofushi, Y., Shinjo, K., Osuka, S., Hariyama, Y., Ito, M., Ohno, K., Kiyono, T., Kyo, S., Iwase, A., Kikkawa, F., Kajiyama, H., & Kondo, Y. (2023). Fusobacterium infection facilitates the development of endometriosis through the phenotypic transition of endometrial fibroblasts. Science translational medicine, 15(700), eadd1531. https://doi.org/10.1126/scitranslmed.add1531
Bendifallah, S., Suisse, S., Puchar, A., Delbos, L., Poilblanc, M., Descamps, P., Golfier, F., Jornea, L., Bouteiller, D., Touboul, C., Dabi, Y., & Daraï, E. (2022). Salivary MicroRNA Signature for Diagnosis of Endometriosis. Journal of clinical medicine, 11(3), 612. https://doi.org/10.3390/jcm11030612
[Dr. Mark Hoffman]
Okay, so you've got a patient. You're suspicious that they have endometriosis based on history, touched on it a little bit. What are the exam findings that make you think a patient is more likely to have endometriosis, less likely to have endometriosis?
[Dr. Ted Lee]
I do, obviously, see the patients. Obviously, see how their general behavior is and everything before I even start the exams. I usually tell the patient exactly what I'm going to do and the reason, the purpose behind my exams.
[Dr. Mark Hoffman]
[Dr. Ted Lee]
Yes, I tell the patients that, "I'm going to palpate different regions in your pelvis. I want you to tell me whether I reproduce your pain or produce a different kind of pain altogether. The better I can reproduce your pain, the more likely I can help you. I also tell them about, I perform a rectovaginal exam on all my patients with pelvic pain, essentially. It's not something that everybody does. For them, it's the first time for them to have rectovaginal exams. I tell them exactly the reason behind that I do the rectovaginal exam. I tell them that the most common site of endometriosis is going to be the cul-de-sac or uterosacral ligament, and it's a lot easier for me to access that area with the finger in the rectum.
[Dr. Mark Hoffman]
Are you feeling for big nodules or are you feeling for nodularity? Is it pretty subtle sometimes, the findings on the--
[Dr. Ted Lee]
Most of patient don't have nodules. Most patient with endometriosis are not going to have nodules. Nodule is a sign of late disease. It's, obviously, when you feel nodules you know that deep infiltrating endometriosis. Majority of the patients just going to have localized tenderness in the area. Usually, most people don't know how to do rectovaginal exam. Obviously, this is a podcast. People have to use their imagination to see how I do the exam. I have one finger, my index finger in the vagina, my middle finger in the rectum.
I have my middle rectal finger palpate anteriorly, and then I feel the cervix. Cervix is a very reliable landmark you can feel on the recto exam because it's firm. We all know that uterosacral ligament is there behind the cervix, so on either side of the cervix would be the uterosacral ligament. If you sweep it laterally and posteriorly, that would be your uterosacral ligament. Whatever is in between, it's the cul-de-sac. If you touch that part of the pelvis and you reproduce the pain, the reaction that I describe as a visceral reaction to the exam, I feel pretty confident that those patients very, very likely would have endometriosis.
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