Diagnosing endometriosis visually

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An experienced surgeon may also recognize endometriosis visually, and he may not biopsy at all if he sees obvious disease. Visual diagnosis also avoids the rare but serious complications of biopsy. Given the advantages of visual diagnosis, having an experienced surgeon who knows what he's looking at and is comfortable with the procedure is of utmost importance.

Keeping calm in the MRI

Many offices now tout their MRIs as being open and less likely to cause claustrophobia, but their definition of open and yours may differ! If you're claustrophobic, undergoing an MRI even in an open tube is a stressful experience. You need to remain as still as possible, the machine makes ominous noises, and even though the side may not be totally enclosed, you will still be surrounded by metal. How can you get through the test without trying to escape in the middle of it?

First of all, remember that someone is always within hollering distance in the room — they don't just walk away and leave you there. Just knowing someone is nearby can be comforting.

Then, to get through the procedure, keep your eyes closed to take your mind off the close walls. Earplugs also help block out noise. They may allow you to move your fingers a bit (sometimes just being able to move any part is comforting!). But always ask whether this movement will interfere with your test. And don't worry — they don't strap you in!

^sNOTjjjp Many times I've seen new patients whose endometriosis was obviously missed during an earlier surgery. The previous surgeon may have not recognized the disease because he was relying on the textbook description — a classic powder-burn lesion appearance. We now identify that traditional appearance as end-stage disease (check out "Staging Endometriosis" later in this chapter for more info). In reality, endometriosis can take on many varied disguises, and surgeons must be trained and experienced to recognize them.

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Lesions: Up close and personal

When bits of endometrial tissue turn into endometriosis, the resulting lesions don't look like your regular menstrual flow. So, what does endometriosis look like to the naked eye? Well, it depends. The tissue can appear very different from one woman to another when a surgeon views it through the laparoscope or with his own eyes. Endometriosis from different areas in the same woman can even look totally different from each other.

Endometriosis can be any one of a number of colors — black, blue, red, white, brown, or clear — depending on where it is, how old the lesions are, and what kinds of cells they contain. The tissue can be flat, raised, regular, or irregular; it can be thin, thick, deep, or shallow. The endometriosis can consist of many adhesions or none. In short, endometriosis is variable in appearance; it has no definitive descriptions.

The classic description of endometriosis, which many textbooks still use, is the powder burn and stellate lesion. Early surgeons saw these structures as obviously abnormal tissue because the abdominal cavity and pelvis have a pink color and the ovaries are white. Note: Your pelvic cavity has other shades of red, blue, and gray hanging around, but nothing is dark gray to black (powder burn) with whitish, thin bands of firm tissue that spread out from the structure (the starlike, stellate, lesions).

The colors of a rainbow: Significant differences

Endometriosis can have many different appearances depending on the stage (See the section "Staging Endometriosis" later in this chapter) and age of the disease. In fact, a patient can have all the different lesions at the same time! The lesions can appear as clear vesicles, or they can be yellow-brown, red, dark red, dark brown, or black areas on the effected surfaces. Your doctor may encounter the following features of these colored lesions:

1 Clear: Although clear isn't exactly a color, the clear blebs (little bubblelike areas) are the earliest signs of endometriosis. They may be hard to see, but, as instruments have improved, the blebs have become clearer to the surgeon. Still, many doctors ignore them or misdiagnose them as bubbles (from the procedure's fluid and gas) or as artifact. A surgeon must have experience and training to find and confidently diagnose these structures as endometriosis.

1 White, yellowish to light brown: This next stage of lesions is more visible, but a surgeon may misinterpret the lesions as remnants of the corpus luteum (the leftover shell of the egg follicle) or other fairly normal conditions (such as bruising from instruments to blood vessels under the peritoneum). These lesions are often flat but may be raised slightly. They're soft, so a surgeon can usually rub them off the surface of a structure. This stage of lesions can occur anywhere, and it's metaboli-cally (chemically) very active.

1 Red: These lesions vary from bright red (like fresh blood) to dark red, almost brown. They can occur anywhere and take on various shapes — round, elongated, long and thin, and so on. These lesions may be more invasive because they're older than the white to light brown variety. Red lesions may be deep and nodular, which leads to scarring. When a surgical instrument enters one of these lesions, a dark fluid (old blood) often emerges. These structures are very obvious and common examples of endometriosis.

1 Dark gray to black: The classic lesions have a gun-powder burn color and represent the disease's end stage. The immune system has attacked the disease, and the endometriosis is now scarred and mostly nonre-sponsive to the menstrual cycle hormones. However, the damage is done. Lesions have destroyed or distorted nearby tissues, and scarring has stuck organs together (called a frozen pelvis) or caused pain and dysfunction.

All these lesions can occur in the same patient at the same time. Because the earlier blebs and yellow lesions are the most metabolically active, women who have them also have the most symptoms. Researchers note that the women with the least apparent disease can have the most symptoms. The reason for this apparent paradox is that these women have plenty of endometriosis — it just hasn't been correctly recognized.

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