Consensus on current management of endometriosis

Sir, We welcome the recent consensus statement from the World Endometriosis Society (WES) on the current management of endometriosis (Johnson and Hummelshoj, 2013). It was a timely article unique in its methodology, especially its process of global networking and the inclusion of the views of women who suffer from endometriosis. The recommendations on the management of endometriosis in low resource settings and the development of centres (or networks) of expertise are commendable. However, we feel that the non-inclusion of transvaginal ultrasound scan as a non-invasive diagnostic tool of choice in the primary evaluation of women suspected of endometriosis is a significant omission. Firstly, evidence has evolved on the role of the transvaginal ultrasound scan in the preoperative management of women with extra-ovarian endometriosis (Dessole et al., 2003; Abrao et al, 2007; Hudelist et al., 2011; Benacerraf and Groszmann, 2012). In particular, pattern recognition of the sonographic characteristics of deep infiltrating endometriosis (DIE) of the posterior pelvic compartment has been well described (Bazot et al., 2007). Furthermore, ultrasound techniques that assess the status of the pouch of Douglas (POD) have also been described (Reid et al., 2013). This is especially important as >60% of women with an obliterated POD will have evidence of bowel endometriosis (Khong et al., 2011). Indeed, a systematic preoperative ultrasonographic assessment of the pelvis has demonstrated a high detection rate and low false-positive rate in predicting POD obliteration and presence of midline DIE in women with high stage disease (Reid et al., 2011). Preoperative ultrasound evaluation therefore provides a stepwise approach to the diagnosis of higher stage disease giving valuable preoperative information. It has the potential to facilitate the triaging of women to the appropriate network of expertise. And with the failure of laparoscopy to sometimes correctly estimate the extent of bowel endometriotic disease in the posterior compartment and incompletely excise ‘skip’ lesions, preoperative imaging enables the laparoscopic surgeon to plan the surgical procedure within the context of a multidisciplinary team approach. Furthermore, we also believe that maximum cyto reduction at the first surgical procedure is best achieved with preoperative mapping of location and extent of disease using transvaginal ultrasound scan. This has the potential to avoid the need for a diagnostic laparoscopy (Menakaya et al., 2013), reduce patient exposure to anaesthesia and result in significant cost savings for the health system. Secondly, transvaginal ultrasound scan is a low cost readily available non-invasive diagnostic tool that has been subjected to robust evaluation of its accuracy in predicting posterior compartment endometriotic disease (Abrao et al., 2007). In contrast to the serum biomarkers described in the consensus paper, transvaginal pelvic ultrasound is ready for immediate introduction into clinical practice even in low resource settings.