Pain every month and normal exams? Understand if it could be endometriosis

There are many cases in which a normal exam means that it found nothing, rather than that there is nothing. On the other hand, having symptoms similar to those of endometriosis also does not confirm the disease, because other conditions cause similar pain. Between false reassurance and hasty conclusions, the way forward is to correlate three things: the symptoms, the clinical examination and the appropriate tests.

According to Tiago Castilho, an oncological surgeon who works in gynecological surgery and deep endometriosis surgery, a negative result on ultrasound or MRI does not completely exclude endometriosis, especially superficial disease, which is in the layer that covers the pelvis. "A normal exam is not proof of the absence of endometriosis. The image helps us map the disease, but it has limits. The patient's pain and history continue to be the main compass for diagnosis, because we treat people, not exams", he states.

Furthermore, the result depends on who takes the exam. In an article on the subject, Tiago Castilho recalls that both ultrasound with bowel preparation and MRI depend on a radiologist trained in endometriosis and modern equipment, and that MRI can give a false negative when this experience is lacking.

Blood tests also do not help with this calculation. The European guideline recommends not using markers, such as CA-125, to diagnose endometriosis, so a normal value says nothing either for or against.

The same guideline advises to consider the disease in those who have severe colic, deep pain during sexual intercourse, pain when having a bowel movement, bleeding in the intestine or urine during the menstrual period, fatigue and difficulty getting pregnant. And it goes further: even if the clinical examination is normal, the investigation must not stop, and other steps, including imaging, must be considered.

When the image shows nothing, but the symptoms continue, the guideline points out two possible paths: trying hormonal treatment to see if the symptoms improve, the so-called empirical treatment, or having a laparoscopy, video surgery that allows you to see and treat the disease. Neither is automatically better, and the choice must be discussed with the patient. Laparoscopy is indicated when the image is negative or when empirical treatment does not work.

"A normal result does not mean the absence of pain, and pain that continues should not be ruled out. The doctor's role is to cross-reference the history, clinical examination and imaging, and reevaluate the investigation when symptoms persist", explains Tiago Castilho.

To better understand what each exam shows and what it doesn't, see the article The two main imaging tests for identifying endometriosis that you need to know. And, for an individual assessment, see how the service works.

For more than 10 years serving and operating on women with endometriosis, Tiago Castilho works with individualized assessment and planning of complex cases. His experience includes videolaparoscopy and robotic surgery and, when surgery is indicated, follow-up can be structured through 360º Care.