Identifying Diaphragmatic Endometriosis

In rare cases, endometriosis can spread beyond the pelvis. Learn the elusive signs of diaphragmatic endometriosis and how to diagnose it.

About 11 percent of gynecology patients of reproductive age will develop endometriosis. In a small percentage of those patients, endometrial tissue can be found in the diaphragm. Diaphragmatic endometriosis can be difficult to diagnose, in part because it is extremely rare and in part because its symptoms may mimic those of other conditions. Knowing when to look and how to spot it is key to timely treatment.

Diaphragmatic Endometriosis Symptoms

In the majority of endometriosis cases, endometrial tissue found outside the uterus is located in the pelvis. However, that tissue may spread to the abdominal cavity and the diaphragm. Some patients have no symptoms and only discover the spread of endometrial tissue incidentally during a screening or unrelated imaging.

According to research published in the Journal of the Society of Laparoscopic and Robotic Surgeons (JSLS), women who do have symptoms may experience upper abdominal pain, chest pain, shoulder pain, difficulty breathing or a persistent cough. Some women may even present with nausea or vomiting. Pain almost always occurs on the right side. These symptoms may cause physicians to suspect a lung condition, asthma or appendicitis.

To distinguish endometriosis of the diaphragm from other conditions, physicians should ask:

  • Do the symptoms occur along with menses?
  • Does this patient have a history of pelvic endometriosis, especially recurrent endometriosis?
  • Does this patient have a history of infertility?

A patient's age at the onset of symptoms can also help with differential diagnosis. The JSLS researchers found that diaphragmatic endometriosis appears most often around age 35 — five to ten years later than most cases of pelvic endometriosis.

Diagnosing Diaphragmatic Endometriosis

Diaphragmatic endometriosis affects between 1 and 1.5 percent of women with endometriosis, according to research published in the International Journal of Fertility and Sterility. Because the condition is rare, there is no standardized approach to diagnosis and treatment.

Imaging tests can help identify the presence of lesions in the abdomen or pelvis. Because pelvic endometriosis is often recurrent, regular monitoring with 3D ultrasound can help support a differential diagnosis when thoracic symptoms arise. An abdominal ultrasound may also help identify lesions. MRI and CT scans are commonly used to look for endometriosis in the diaphragm and abdomen.

Diaphragmatic endometriosis is most frequently found on the right side, but lesions can also appear on the left side, on both sides or in the phrenic nerve. Imaging should look for signs in the anterior and posterior portion of the diaphragm behind the liver, according to the International Journal of Fertility and Sterility study.

However, other recent research notes that only a small fraction of cases are spotted on presurgical imaging, especially when it is asymptomatic. Any spreading to the diaphragm is most often discovered during surgery for pelvic endometriosis.

Imaging is only the first step in looking for the spread of disease and possible abdominal involvement. A definitive diagnosis can only be made with laparoscopy and histopathological examination of tissue.

Laparoscopic evaluation of tissue can help classify the lesions based on their thickness and infiltration. Lesions are classified as foci, nodules and plaques. Surgery is the most common treatment for these lesions, although no specific treatment guidelines exist yet. Classifying the lesions can help guide a surgical approach.

Because diaphragmatic endometriosis is rare and often asymptomatic, it is important to know when to look for it. Gynecologists should consider the condition when patients present with both pelvic endometriosis and thoracic symptoms. Recognizing the signs can help ensure patients get relief sooner.