Ms Deslandes led a systematic review of 35 articles, published in the Journal of Ultrasound in Medicine , that found TVUS can be a valuable and accurate diagnostic tool for deep-infiltrating endometriosis — the most severe and challenging type to manage. It can cause severe pain with periods, sex, passing urine and bowel movements — varying from constipation to diarrhoea and bloating, as well as heavy or dysfunctional menstrual bleeding.
Left untreated, however, the condition can have long term consequences such as fertility problems and, in extreme cases, renal failure. Despite estimates that one in nine women in Australia live with endometriosis, it can take 7—10 years for women to receive a diagnosis from their first presentation.
Dr Moten says this statistic reflects the difficult in detecting and managing the condition. While TVUS is relatively low-cost and readily available, there can be barriers to accessing it, as in urban areas it is typically only offered by specialised gynaecologists. It is a test that can help patients and their doctors understand the severity of endometriosis.
In our opinion, when an ultrasound is performed by a colleague who has received high quality training in the diagnosis of endometriosis, and it is normal, this does not mean there is no endometriosis. In fact, many people with the classic symptoms of endometriosis and a normal scan do have superficial endometriosis. What this ultrasound result tells us is that there is no ovarian endometriosis or deeply infiltrating endometriosis, which is important to know when thinking about treatment options.
On the other hand, when we see endometriosis on ultrasound and can tell that it is ovarian endometriosis or deeply infiltrating endometriosis, this eliminates the need to perform a keyhole surgery for diagnosis. The knowledge of severe endometriosis can help a person with endometriosis find an accredited endometriosis centre.
In time, our hope is that all people with symptoms suggestive of endometriosis can access high quality transvaginal ultrasound by healthcare professionals trained to look for and see endometriosis. When this happens, the keyhole surgery for diagnosis will become a thing of the past. We believe that no person should have to undergo a surgical procedure to receive an endometriosis diagnosis.
Finding ultrasound techniques and new bloods tests should help tackle delays in diagnosis. Until then, as gynaecologists, we recommend that people with symptoms of possible endometriosis should advocate for themselves to have an ultrasound scan performed by a colleague who has undertaken specialised training in endometriosis diagnosis.
This advocacy should motivate all colleagues who perform transvaginal ultrasound to learn the necessary skills to provide the required specialised diagnostic service. There is a vibrant online community of women with endometriosis, commonly known as endosisters, who share knowledge and offer support, along with charities such as Endometriosis UK and grassroots organisations such as Fair Treatment for the Women of Wales.
You can find out more in the blog Endometriosis: MyEndometriosisQuestion — a special series, including how to ask your question on our social media platforms, or you can post your question below this blog. While our experts cannot give specific medical advice, they can provide information about endometriosis, relevant evidence and guidelines, and tips for discussing endometriosis with your own health professional.
Our expert panel will do their best to answer your questions individually. They will also reflect on some of the submitted questions in a blog to be published at the end of the month. No individuals will be named or identified in this blog. Comments are checked by the Editors before they are made public on the blog. Please note, we cannot give specific medical advice and do not publish comments that link to individual pages requesting donations or to commercial sites, or appear to endorse commercial products.
We welcome diverse views and encourage discussion but we ask that comments are respectful and reserve the right to not publish any we consider offensive. References and further reading pdf. Dr Duffy has nothing to disclose. His clinical interests include endometriosis, reproductive medicine, and gynaecological surgery. He is an advanced gynaecological surgeon and sonologist ultrasound expert. His clinical interests include endometriosis, gynaecological surgery, and ultrasound. The literature supports use of ultrasound for endometriosis.
Reid et al. In , the IDEA group published a consensus opinion with the aim of increasing awareness, improving education on endometriosis ultrasound mapping, and decreasing heterogeneity between published reports on diagnostic accuracy. A classic example is use of the term rectovaginal endometriosis, which is not a true anatomic structure but a general area.
The IDEA consensus opinion publication and growing expertise in endometriosis ultrasound both broadly and locally should actually yield even greater diagnostic accuracy now than in the past. There is no one right way to perform ultrasound to diagnose endometriosis, 14,18,20,21 as long as the imaging is done thoroughly and systematically.
We have published a step-by-step method that is Free Access to all in the Australasian Journal of Ultrasound in Medicine. Here, we describe the appearance of the three different endometriosis phenotypes—OEs, DE, and SE—and the best-known methods for detecting them.
All descriptions, figures, and videos below are relevant to TVS. OEs are the most common. As such, we will first describe scanning in the adnexa, then discuss the anterior and posterior compartments for DE, and finally, touch upon advances in ultrasound for SE. For an elaborate discussion of atypical OEs, please refer to Van Holsbeke et al. Ovarian mobility must be assessed, regardless of the presence of an OE.
Ovarian immobility is more often seen in the context of OEs. An OE should raise a red flag for DE elsewhere in the pelvis, 24,25 often in the posterior compartment. Anatomical distortion is common in patients with endometriosis and occasionally results in tubal blockage.
The inability of fluid to transit through the tubes may result in the development of a hydrosalpinx or hematosalpinx. When these abnormalities are identified, endometriosis should be entertained. The posterior compartment is the most common site of DE. When there is fluid in the rectouterine pouch, the boundary of the retro- and intraperitoneal rectum and the most superior aspect of the RVS are easier to visualize See Figure 7. At the maximum insertion depth, when the probe is positioned posterior to the cervix, the PVF can be appreciated as the hypoechoic layer in direct contact with the probe.
A sweep from one side to the other should be done to observe the entire posterior vagina See Video 5. DE of the retroperitoneal rectum or RVS is rare, but when present, you should note whether the lesion lies within one specific anatomic area or extends between areas e. DE of the PVF is characterized by significant and focal thickening of the vagina and sometimes can be distinguished from the surrounding normal vagina by its slight hypoechoic nature See Figure 8.
Clinicians should always directly visualize the vagina on speculum examination. Ultrasound operators should assess the proximity of another normal or abnormal anatomical structure to the PVF DE. The rectum is very close and may be tethered, even when not directly affected by DE itself See Video 6.
If surgical excision is planned, it may be prudent to measure the distance between the PVF DE and the closest aspect of the rectum. DE of the bowel generally occurs in the muscularis externa layer and does not infiltrate through to the mucosa Figures 9 through 12 , Video 7.
A normal bowel wall is depicted in Video 8. The anterior rectum, which begins after the bowel transitions from retroperitoneal to intraperitoneal, is the most common site of DE in the bowel. It is possible, although more challenging, to visualize rectosigmoid junction or sigmoid colon DE because of the physical distance between the probe and the disease.
The goal is to follow the bowel wall as long as possible. The distance from the lowest nodule to the anal verge should be measured to assist in surgical planning as the type and location of bowel surgery has implications on surgical risk.
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