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. 2016 Jul 13;7(7):CD012281.
doi: 10.1002/14651858.CD012281.

Combination of the non-invasive tests for the diagnosis of endometriosis

Vicki Nisenblat  1 , Lucy Prentice, Patrick M M Bossuyt, Cindy Farquhar, M Louise Hull, Neil Johnson
Affiliations

Combination of the non-invasive tests for the diagnosis of endometriosis

Vicki Nisenblat et al. Cochrane Database Syst Rev. .

Abstract

Background: About 10% of women of reproductive age suffer from endometriosis, a costly chronic disease causing pelvic pain and subfertility. Laparoscopy is the gold standard diagnostic test for endometriosis, but is expensive and carries surgical risks. Currently, there are no non-invasive tests available in clinical practice to accurately diagnose endometriosis. This review assessed the diagnostic accuracy of combinations of different non-invasive testing modalities for endometriosis and provided a summary of all the reviews in the non-invasive tests for endometriosis series.

Objectives: To estimate the diagnostic accuracy of any combination of non-invasive tests for the diagnosis of pelvic endometriosis (peritoneal and/or ovarian or deep infiltrating) compared to surgical diagnosis as a reference standard. The combined tests were evaluated as replacement tests for diagnostic surgery and triage tests to assist decision-making to undertake diagnostic surgery for endometriosis.

Search methods: We did not restrict the searches to particular study designs, language or publication dates. We searched CENTRAL to July 2015, MEDLINE and EMBASE to May 2015, as well as the following databases to April 2015: CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, DARE and PubMed.

Selection criteria: We considered published, peer-reviewed, randomised controlled or cross-sectional studies of any size, including prospectively collected samples from any population of women of reproductive age suspected of having one or more of the following target conditions: ovarian, peritoneal or deep infiltrating endometriosis (DIE). We included studies comparing the diagnostic test accuracy of a combination of several testing modalities with the findings of surgical visualisation of endometriotic lesions.

Data collection and analysis: Three review authors independently collected and performed a quality assessment of the data from each study by using the QUADAS-2 tool. For each test, the data were classified as positive or negative for the surgical detection of endometriosis and sensitivity and specificity estimates were calculated. The bivariate model was planned to obtain pooled estimates of sensitivity and specificity whenever sufficient data were available. The predetermined criteria for a clinically useful test to replace diagnostic surgery were a sensitivity of 0.94 and a specificity of 0.79 to detect endometriosis. We set the criteria for triage tests at a sensitivity of 0.95 and above and a specificity of 0.50 and above, which 'rules out' the diagnosis with high accuracy if there is a negative test result (SnOUT test), or a sensitivity of 0.50 and above and a specificity of 0.95 and above, which 'rules in' the diagnosis with high accuracy if there is a positive result (SpIN test).

Main results: Eleven eligible studies included 1339 participants. All the studies were of poor methodological quality. Seven studies evaluated pelvic endometriosis, one study considered DIE and/or ovarian endometrioma, two studies differentiated endometrioma from other ovarian cysts and one study addressed mapping DIE at specific anatomical sites. Fifteen different diagnostic combinations were assessed, including blood, urinary or endometrial biomarkers, transvaginal ultrasound (TVUS) and clinical history or examination. We did not pool estimates of sensitivity and specificity, as each study analysed independent combinations of the non-invasive tests.Tests that met the criteria for a replacement test were: a combination of serum IL-6 (cut-off >15.4 pg/ml) and endometrial PGP 9.5 for pelvic endometriosis (sensitivity 1.00 (95% confidence interval (CI) 0.91 to 1.00), specificity 0.93 (95% CI, 0.80, 0.98) and the combination of vaginal examination and transvaginal ultrasound (TVUS) for rectal endometriosis (sensitivity 0.96 (95% CI 0.86 to 0.99), specificity 0.98 (95% CI 0.94 to 1.00)). Tests that met the criteria for SpIN triage tests for pelvic endometriosis were: 1. a multiplication of urine vitamin-D-binding protein (VDBP) and serum CA-125 (cut-off >2755) (sensitivity 0.74 (95% CI 0.60 to 0.84), specificity 0.97 (95% CI 0.86 to 1.00)) and 2. a combination of history (length of menses), serum CA-125 (cut-off >35 U/ml) and endometrial leukocytes (sensitivity 0.61 (95% CI 0.54 to 0.69), specificity 0.95 (95% CI 0.91 to 0.98)). For endometrioma, the following combinations qualified as SpIN test: 1. TVUS and either serum CA-125 (cut-off ≥25 U/ml) or CA 19.9 (cut-off ≥12 U/ml) (sensitivity 0.79 (95% CI 0.64 to 0.91), specificity 0.97 (95% CI 0.91 to 1.00)); 2. TVUS and serum CA 19.9 (cut-off ≥12 U/ml) (sensitivity 0.54 (95% CI 0.37 to 0.70), specificity 0.97 (95% CI 0.91 to 1.0)); 3-4. TVUS and serum CA-125 (cut-off ≥20 U/ml or cut-off ≥25 U/ml) (sensitivity 0.69 (95% CI 0.49 to 0.85), specificity 0.96 (95% CI 0.88 to 0.99)); 5. TVUS and serum CA-125 (cut-off ≥35 U/ml) (sensitivity 0.52 (95% CI 0.33 to 0.71), specificity 0.97 (95% CI 0.90 to 1.00)). A combination of vaginal examination and TVUS reached the threshold for a SpIN test for obliterated pouch of Douglas (sensitivity 0.87 (95% CI 0.69 to 0.96), specificity 0.98 (95% CI 0.95 to 1.00)), vaginal wall endometriosis (sensitivity 0.82 (95% CI 0.60 to 0.95), specificity 0.99 (95% CI 0.97 to 1.0)) and rectovaginal septum endometriosis (sensitivity 0.88 (95% CI 0.47 to 1.00), specificity 0.99 (95% CI 0.96 to 1.00)).All the tests were evaluated in individual studies and displayed wide CIs. Due to the heterogeneity and high risk of bias of the included studies, the clinical utility of the studied combination diagnostic tests for endometriosis remains unclear.

Authors' conclusions: None of the biomarkers evaluated in this review could be evaluated in a meaningful way and there was insufficient or poor-quality evidence. Laparoscopy remains the gold standard for the diagnosis of endometriosis and using any non-invasive tests should only be undertaken in a research setting.

PubMed Disclaimer

Conflict of interest statement

Cindy Farquhar is a director/shareholder of a fertility/gynaecology clinic and undertakes private practice within those premises.

Neil Johnson is involved in research funded by Abb‐Vie. He has received support to attend conferences from MSD, Merck‐Serono and Bayer. He has been on an advisory board for Vifor Pharma.

No other authors have any conflict of interest to declare.

Figures

1
1
Sequential approach to non‐invasive testing of endometriosis
2
2
Flow of the studies identified in literature search for systematic review on combination of non‐invasive tests for diagnosis of endometriosis.
3
3
Risk of bias and applicability concerns summary: review authors' judgements about each domain for each included study
4
4
Risk of bias and applicability concerns graph: review authors' judgements about each domain presented as percentages across included studies
5
5
Forest plot of the combined tests for detection of pelvic endometriosis. Plot shows the estimates of sensitivity and specificity (squares) with 95% CI (black line) specific for each evaluation (each evaluation was derived from a single study), country in which the study was conducted and severity of the disease assessed by each study, reported as rASRM stage. FN: false negative; FP: false positive; TN: true negative; TP: true positive.
6
6
Study specific estimates of the diagnostic accuracy of the combined tests for detection of pelvic endometriosis plotted in ROC space. Each point represents the pair of sensitivity and specificity from each evaluation (each evaluation was derived from a single study). The size of each point is proportional to the sample size the shape designates different tests. The bars correspond to 95% CIs of each individual evaluation.
7
7
Forest plot of the combined tests for detection of DIE or ovarian endometriosis. Plot shows the estimates of sensitivity and specificity (squares) with 95% CI (black line) specific for each evaluation (each evaluation was derived from a single study), country in which the study was conducted and type of target condition assessed by each study. FN: false negative; FP: false positive; TN: true negative; TP: true positive.
8
8
Study specific estimates of the diagnostic accuracy of the combined tests for detection of DIE or ovarian endometriosis plotted in ROC space. Each point represents the pair of sensitivity and specificity from each evaluation (each evaluation was derived from a single study). The size of each point is proportional to the sample size the shape designates different tests. The bars correspond to 95% CIs of each individual evaluation.
9
9
Forest plot of the combined tests (TVUS and/or CA‐125 and/or CA‐19.9) for differentiation of ovarian endometriosis vs. other benign ovarian cysts. Plot shows the estimates of sensitivity and specificity (squares) with 95% CI (black line) specific for each evaluation (each evaluation was derived from a single study Guerriero 1996a), country in which the study was conducted and target condition assessed by each study. FN: false negative; FP: false positive; TN: true negative; TP: true positive.
10
10
Study specific estimates of the diagnostic accuracy of the combined tests (TVUS and/or CA‐125 and/or CA‐19.9) for differentiation of ovarian endometriosis vs. other benign ovarian cysts plotted in ROC space. Each point represents the pair of sensitivity and specificity from each evaluation (each evaluation was derived from a single study Guerriero 1996a). The size of each point is proportional to the sample size the shape designates different tests. The bars correspond to 95% CIs of each individual evaluation.
11
11
Forest plot of the combined tests (TVUS and/or CA‐125 at varying thresholds) for differentiation of ovarian endometriosis vs. other benign ovarian cysts. Plot shows the estimates of sensitivity and specificity (squares) with 95% CI (black line) specific for each evaluation (each evaluation was derived from a single study Guerriero 1996b), country in which the study was conducted and target condition assessed by each study. FN: false negative; FP: false positive; TN: true negative; TP: true positive.
12
12
Study specific estimates of the diagnostic accuracy of the combined tests (TVUS and/or CA‐125 at varying thresholds) for differentiation of ovarian endometriosis vs. other benign ovarian cysts plotted in ROC space. Each point represents the pair of sensitivity and specificity from each evaluation (each evaluation was derived from a single study Guerriero 1996b). The size of each point is proportional to the sample size the shape designates different tests. The bars correspond to 95% CIs of each individual evaluation.
1
1. Test
IL‐6 (>15.4 pg/ml) [serum] + PGP 9.5 [endometrium].
2
2. Test
CA‐125 [serum] (>35 U/ml) + P450 aromatase [endometrium].
3
3. Test
VDBP‐Cr [urine] x CA‐125 [serum] (>2755).
4
4. Test
NNE_Cr [urine] + CA‐125 [serum] (>27.23).
5
5. Test
Hx (dysmenorrhoea, dyspareunia) + PV examination + TVUS (fixed ovary).
6
6. Test
Hx (length of menses) + CA‐125 [serum] (>35 U/ml) + leukocytes [endometrium].
7
7. Test
Hx (parity, past IUD, past endometriosis, alcohol intake, dyspareunia) + CA‐125 [serum].
8
8. Test
PV examination (menstrual nodularities) + CA‐125 [serum] (>35 IU/ml) for DIE, endometrioma or severe adhesions.
9
9. Test
PV examination (menstrual nodularities) OR CA‐125 [serum] (>35 IU/ml) for DIE, endometrioma or severe adhesions.
10
10. Test
PV examination (menstrual nodularities) + CA‐125 [serum] (>35 IU/ml) for DIE.
11
11. Test
PV examination (menstrual nodularities) OR CA‐125 [serum] (>35 IU/ml) for DIE.
12
12. Test
PV examination (menstrual nodularities) + CA‐125 [serum] (>35 IU/ml) for endometrioma.
13
13. Test
PV examination (menstrual nodularities) OR CA‐125 [serum] (>35 IU/ml) for endometrioma.
14
14. Test
TVUS + CA‐125 [serum] (≥25 U/ml) + CA‐19.9 [serum] (≥12 U/ml).
15
15. Test
TVUS + (CA‐125 [serum] (≥25 U/ml) OR CA‐19.9 [serum] (≥12 U/ml)).
16
16. Test
TVUS + CA‐19.9 [serum] (≥12 U/ml).
17
17. Test
TVUS OR CA‐19.9 [serum] (≥12 U/ml).
18
18. Test
TVUS + CA‐125 [serum] (≥20 U/ml).
19
19. Test
TVUS OR CA‐125 [serum] (≥20 U/ml).
20
20. Test
TVUS + CA‐125 [serum] (≥25 U/ml).
21
21. Test
TVUS OR CA‐125 [serum] (≥25 U/ml).
22
22. Test
TVUS + CA‐125 [serum] (≥35 U/ml).
23
23. Test
TVUS OR CA‐125 [serum] (≥35 U/ml).
24
24. Test
PV examination + TVUS for POD obliteration.
25
25. Test
PV examination + TVUS for vaginal endometriosis.
26
26. Test
PV examination + TVUS for RVS endometriosis.
27
27. Test
PV examination + TVUS for rectal endometriosis.
See this image and copyright information in PMC

References

References to studies included in this review

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