In this episode of PodMD, Obstetrician and Advanced Gynaecological Surgeon Dr Nargis Noori will be discussing the topic of endometriosis. We discuss what endometriosis is, how patients would typically present, how it’s diagnosed, and more.
- Transcript
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*As always, all in this PodMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Nargis Noori.
Dr Noori is a Minimally Invasive Obstetrician and Advanced Gynaecological Surgeon providing care in Westmead.
After graduating with Honours in Medical Science, Nargis completed her medical degree at the University of Sydney. She then pursued specialist training in Obstetrics and Gynaecology through placements at Nepean Hospital, Westmead Hospital and Orange Base Hospital. Dr Noori has broad clinical experience in managing a variety of patients with complex conditions.
She is dedicated to offering her patients an experience rooted in empathy and understanding, consistently prioritising exceptional care in pregnancy and gynaecological health.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD. If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.
Today, we’ll be discussing the topic of endometriosis. Nargis, thanks for talking with us on PodMD today.
Nargis: Thanks for having me.
So the topic of today’s discussion is endometriosis. Nargis, can you describe for our listeners what endometriosis is?
Nargis: Sure. So basically, at its core, endometriosis is a chronic condition where tissue that looks and acts a lot like the endometrial lining shows up in other anatomical places. Most often that’s within the pelvis on structures like the ovaries, the fallopian tubes, the peritoneal lining, bowel, or even bladder. Now, just like the uterine lining, this tissue responds to hormonal changes during the menstrual cycle. The difference, however, being outside the uterus, this response is usually in the form of inflammation, scarring, and adhesions.
Question 1
Perfect. And how would a patient with endometriosis typically present?Nargis: So when we talk about symptoms of endometriosis, it’s quite important to remember that they do go well beyond just painful or bad periods. The symptom profile can be broad and often quite debilitating. The most common things that patients report include severe dysmenorrhea. So it’s just pain that’s not just uncomfortable during their periods, but genuinely interferes with day-to-day function.
Going down, I guess, more pain-type symptoms. There’s also cyclical pain patterns, so pain with ovulation, pain during or after intercourse, and pain with bladder or bowel activity. Many patients will also describe a sharp or deep pelvic pain when they’re urinating, when they’re opening their bowels, around their menses, or even just generalised pain in the pelvis, lower back, or even radiating into their legs. Beyond the pain symptoms, there are other symptoms, I guess, that are quite common with presentation.
So fatigue is a big one, and it’s really easy to underestimate how exhausting that ongoing inflammatory burden can be. Other symptoms would include heavy or irregular bleeding and even presentations through infertility.
Question 2
Perfect. And how does endometriosis affect fertility?Nargis: So when it comes to fertility, endometriosis can affect things in a couple of major ways. At the severe end, it can physically distort pelvic anatomy, so blocking or damaging the fallopian tubes, altering ovarian function or forming endometriomas, so large cysts that interfere with ovulation or egg release. But even in mild disease where there’s no obvious distortion, we think there are biochemical factors that play a role. So inflammatory mediators from endometriotic tissue may reduce egg quality, impair sperm function, or even affect implantation.
Having said that, it’s really important to highlight that a diagnosis of endometriosis does not mean automatic infertility. Many women conceive naturally. However, if you do have a patient that’s under 35 and has been trying for over 12 months or over 35 and has been trying for more than six months, a referral to either someone who specialises in endometriosis care or a fertility specialist is probably warranted.
Question 3
And how is endometriosis diagnosed?Nargis: Diagnosis of endometriosis is one of the real challenges we face, and the delay is significant. On average, it still takes about six years or so from symptom onset to diagnosis. A good starting point is always a thorough history and physical examination. So, a bimanual examination can sometimes pick up clues. Things that we look for during a bimanual examination include focal tenderness or nodularity along the uterosacral ligaments or in the patch of Douglas, a fixed uterus, which indicates an obliterated patch of Douglas, enlarged tender adnexal masses suggesting presence of endometriomas. So there’s some things that you may find on a physical examination.
A thorough history is quite important. Obviously, eliciting all those symptoms that we discussed earlier, finding out specific details about the menstrual cycle with regards to pain, as well as the severity and heaviness of bleeding. And then the other symptoms that we discussed, so pain during intercourse, pain with bowel or urine, bladder function. But it’s also worth remembering that there are patients with endometriosis that may be completely asymptomatic and may just present with infertility, or they may have completely normal clinical exams. And this is one of the biggest challenges we have with endometriosis in that the severity of disease is not always apparent through symptoms or even examination. It’s very common to sometimes have patients who have severe symptoms and end up having very little disease when we do laparoscopy.
And similarly, we may have patients that are completely asymptomatic and we only find presence of disease during a laparoscopy for some other reason. So, diagnosis can be quite challenging.
The other thing I guess we can discuss is imaging modalities. There are some imaging modalities that we use quite routinely. However, they too have their limitations. So the two big ones that we see are ultrasound and MRI. There are standard ultrasound and also specialist ultrasounds, so particularly something called a deep infiltrating endometriosis scan or a DIE scan, which are performed by some specialized units. Or even a pelvic MRI, which can be used in cases where the DIE scan is not accessible. These are quite helpful for mapping advanced disease, such as nodules, adnexal masses, or extrapelvic lesions.
The main limitations of these, however, is that they do not pick up superficial disease. And so, we rarely use these imaging modalities for everyone. It is quite individualized. We do, however, rely on these, on ultrasound and MRI sometimes for preoperative planning of advanced disease. Having said all this, the gold standard of diagnosis still remains laparoscopy with histological confirmation. Not every patient needs this, but for many, it provides not only critical information on disease extent, but also an opportunity to treat surgically at the same time. And just as importantly, the validation of a firm diagnosis after years of symptoms.
Question 4
And what is the likelihood of recurrence of the condition, Nargis?Nargis: Endometriosis is unfortunately a condition that can recur even after treatment, as there is no cure for it. The risk is higher in women who are diagnosed at a younger age and in those who have more extensive disease at the time of their initial surgery. We do know that, though, however, that post-operative hormonal suppression does play a big role in reducing recurrence by dampening down the growth of new implants.
Beyond that, there are some other ways of potentially reducing recurrence, such as lifestyle factors in the form of stress management, diet, and regular exercise. They may also help in symptom control, however, the evidence in this is not as robust. The key is to frame endometriosis as a chronic condition. It’s not a one-and-done diagnosis or a single procedure. Patients do best when we manage it with a multidisciplinary approach and a holistic mindset, focusing not just on recurrence prevention, but also on long-term pain control and quality of life.
Question 5
When should a GP refer?Nargis: I think there’s a few scenarios where it would be important for a primary care provider to consider a specialist referral. The first would probably be failed medical management. I think if initial approaches like analgesia or hormonal therapy aren’t effective, or if the patient simply can’t tolerate them, then it’s definitely time to refer to a specialist. Secondly, if symptoms are very severe or persistent, so symptoms of pain, bleeding, or other ones that we’ve discussed earlier, if they’re significant enough that they’re impacting day-to-day life, causing days of missed school or work, or issues with personal relationships, I think that definitely warrants specialist review.
Referral is also important when imaging or examination raises suspicion for endometriosis, whether that’s a large endometrioma or deep infiltrating disease that was picked up on an ultrasound or MRI or any other abnormal findings in this way. The other, I think, reason that might warrant specialist referral would be infertility. So any patient with endometriosis who’s trying to conceive but is struggling should be seen by a gynecologist or a fertility specialist.
And finally, I think irrespective of whether we find disease before referral or not, I think just if there’s enough patient concern. So, if someone is worried about endometriosis and wants further assessment, even in the absence of any dramatic findings, referral is appropriate. So I think, in short, referral, when medical management isn’t enough, when symptoms are severe, when there’s a clinical or imaging findings that point to disease, when there’s fertility impacted, or simply when a patient is asking for answers, those would be the main times a referral would be warranted.
Question 6
Excellent. What role does the GP play in the treatment of the condition?Nargis: I think this is a really crucial question. GPs play a cornerstone role, I think, in endometriosis care. For many patients, they’re the first person that hears their story, and that initial response can have a huge impact on how supported the patient feels. There’s a few ways that GPs can care for endometriosis patients. So advocacy is the 1st way patients often describe years of not being believed or having their symptoms minimised. And having a GP who validates their concerns, recognises the impact on their quality of life, and pushes for timely referral can make an enormous difference.
At the same time, GPs are well placed to offer first-line treatments. So that might include simple analgesia or even hormonal therapy to suppress symptoms. This might not even resolve the issue long-term, but it can definitely offer relief and buy time while a broader management plan is being developed. GPs are also ideally positioned to take a holistic approach. So this means thinking beyond medical therapy of just referring to a gynecologist, but involving allied health where relevant. In particular, looking at pelvic physiotherapists, psychologists, especially for the pain and mental health burden. dietitians, and even pain specialists can all be part of a broader support network for these patients.
And finally, I think just from an ongoing monitoring point of view, GPs play a really important role. Endometriosis is a chronic condition, and so GPs have an important role in tracking symptoms over time, adjusting management plans, and ensuring that continuity of care between these different specialists is maintained. So I think there’s a lot of different roles that GPs play, and they’re definitely very crucial in the ongoing care of these patients.
Question 7
Excellent. Thank you so much for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take-home messages from today’s podcast on endometriosis?Nargis: Sure. Thank you for having me. I think if I had to sum up three key focus points, it would be that endometriosis is more than just painful periods. It’s a chronic, systemic condition with a wide spectrum of symptoms, and it often takes years to diagnose.
The second takeaway message would probably be that diagnosis and management require a very layered approach. So clinical suspicion, careful examination, and sometimes advanced imaging can guide us, but it’s important to note that laparoscopy remains the gold standard for diagnosis. And further to that, treatment has to be individualised based on patient goals, expectations, and requires a multidisciplinary aspect to it.
And finally, to all of this, GPs are quite central to long-term care. They advocate for their patients, they start treatments, and they coordinate all the allied health and specialist referrals, making them very important in managing endometriosis as a chronic condition.
Nargis, thanks again for your time and the insights you’ve provided.
Nargis: No problem. Thank you for having me.
