Despite endometriosis being a relatively common condition, it is challenging to identify and diagnose. For many years, laparoscopic surgery has been the “gold standard” procedure for definitively identifying endometriosis. However, the use of transvaginal ultrasound by experienced sonographers is emerging as a complementary diagnostic method due to its greater accessibility, lower cost and non surgical approach.

The growing use of TVUS as an endometriosis diagnosis and treatment planning tool also signifies a more important role for sonographers, and specialist practices like QUFW.

In this article, we’ll explore: 

1. What is endometriosis?
2. A change in the way endometriosis is diagnosed
3. What is transvaginal ultrasound (TVUS)?
4. The benefits of TVUS
5. The growing importance of sonographers
6. Potential for future advancements
7. Reference
8. Bibliography

---

What is endometriosis?

Endometriosis is a relatively common inflammatory condition in which cells similar to the endometrium (the lining of the uterus) grow in other locations around the body. While endometriosis is commonly found in and around the pelvis and reproductive organs, it can also grow in other parts of the body, including the bowel, bladder, and other organs. 

Common symptoms of endometriosis include abnormal and heavy bleeding, chronic pelvic pain, dysmenorrhea (painful periods) and dyspareunia (pain during or after intercourse) , which can severely affect quality of life and may affect fertility. 

Facts about endometriosis:

• Recent Australian research suggests that endometriosis may affect as many as one in seven women. 
• On average, it takes 6.5 years to be diagnosed with endometriosis, during which patients may experience discomfort, pain, and other symptoms.  
• Endometriosis commonly presents in three different ways: 
  • Superficial endometriosis (SE)
  • Ovarian endometriosis (endometriomas)
  • Deep infiltrating endometriosis (DIE)
• According to Delsandes et al (2024), endometriosis may lead to further complications including:
  • Infertility
  • Bowel obstruction
  • Renal failure
  • Recurrent miscarriage
  • Depression
  • Higher rates of cancer
  • Autoimmune conditions
  • Cardiovascular disease

Endometriosis is a complex condition, which makes its diagnosis and treatment difficult. 

A change in the way endometriosis is diagnosed

Laparoscopic surgery has traditionally been the preferred method of diagnosing endometriosis, which involves a surgical procedure to directly visualise and surgically excise lesions.  Laparoscopy, like all operations, has potential risk, expense and recovery time.

However a medical imaging process called transvaginal ultrasound (TVUS) is being utilised more effectively by suitably trained sonographers as a method for diagnosing endometriosis.  

QUFW Sonographers are skilled and experienced in this process.

What is transvaginal ultrasound (TVUS)?

Transvaginal ultrasound is a diagnostic imaging technique used primarily in gynaecology to obtain detailed images of the female reproductive organs, including the uterus, ovaries, and surrounding areas. This procedure involves the insertion of a small, wand-like device, called a transducer, into the vagina. The transducer emits sound waves that bounce off internal structures, creating echoes that are then converted into images on a monitor. 

This method provides higher resolution images than a transabdominal pelvic ultrasound, allowing for more accurate assessment and diagnosis of conditions such as ovarian cysts, uterine fibroids, early stages of pregnancy, and now endometriosis.

The benefits of TVUS

It has been suggested that transvaginal ultrasound can be used as a first-line imaging method for assessing women with suspected endometriosis (Deslandes Et Al 2024). The assessment however, needs to be performed according to well standardised, established protocols. Transvaginal ultrasound is a noninvasive examination that is not only easily accessible, it is inexpensive but allows for preoperative planning in cases that require surgery. 

Diagnostic features of endometriosis can be very subtle and it is important that the scan is performed by a skilled sonographer. At QUFW we believe that endometriosis assessment should be part of every routine gynaecological examination. 

QUFW has continued interest in continued professional development for our sonographers and has collaborated with leading experts in the field to ensure that we are at the forefront of diagnostic imaging for our patients. Our sonographers have undergone advanced training in detecting endometriosis on ultrasound and follow the International Deep Endometriosis Analysis (IDEA)consensus. This is a four step systematic approach.

The International Deep Endometriosis Analysis (IDEA) consensus has outlined a four-step assessment approach, using TVUS, for the detection of endometriosis:

Assessment Step 1: Uterus and ovaries

Pathology detected:

• Adenomyosis

3D coronal ultrasound image of a uterus demonstrating hyperechogenic myometrial islands commonly seen in adenomyosis.

Ultrasound image of an endometrioma in the left ovary

Assessment Step 2: Ovarian mobility and site-specific tenderness

Pathology detected:

• Ovarian adhesions
• Sites of tenderness which may indicate endometriosis

Assessment of mobility and tenderness of the right ovary by using “probe palpation” via a transvaginal transducer

Ultrasound video clip demonstrating “kissing ovaries”

Assessment Step 3: Anterior compartment (Bladder, Ureters, Vesicouterine space)

Pathology detected:

• Nodules of deep endometriosis within the anterior compartment

Ultrasound video of the anterior compartment demonstrating a deep infiltrating endometriosis bladder nodule

Assessment Step 4: Posterior compartment (Posterior vaginal wall, Uterosacral Ligaments, Rectosigmoid colon, Pouch of Douglas, Rectovaginal septum)

Pathology detected:

• Nodules of deep endometriosis within the posterior compartment

Ultrasound video of a deep infiltrating endometriosis bowel nodule

The growing importance of sonographers

The importance and relevance of transvaginal ultrasound in the detection of endometriosis places sonographers at the forefront of diagnosis.

This is due to:  

• The nuanced skills required to use ultrasound as a medical imaging modality: Sonographers not only use their advanced imaging skills to detect deep endometriosis, but also rely and utilise dynamic imaging to assess for mobility.  Assessing mobility is a limitation of MRI in assessment of endometriosis.
• Identification of subtle signs: Sonographers provide expertise in spotting the specific markers of endometriosis, which can be challenging to detect via other non-invasive means.
• Patient comfort and communication: Sonographers play a key role in ensuring patient comfort during the procedure.
• Collaborative care: Sonographers are vital in the multidisciplinary approach to managing endometriosis, working alongside doctors to tailor patient care.

Potential for future advancements

Emerging techniques and technological developments will continue to advance TVUS as a valuable method for diagnosing endometriosis. Some of these are:

SonoPODography

SonoPODography is an innovative ultrasound-based technique designed for the direct visualisation of superficial endometriosis. This procedure involves the infusion of saline into the pouch of Douglas (POD) via an intrauterine balloon catheter, creating an acoustic window that enhances the ultrasound beam’s ability to visualise the surrounding structures of the pelvis. This method allows for the assessment of the presence or absence of superficial endometriosis using pre-defined features.

Elastography

Elastography is a medical imaging technique that measures the elasticity or stiffness of soft tissue, to detect changes that may indicate disease. It’s often used alongside ultrasound or magnetic resonance imaging (MRI) to add important information about the mechanical properties of tissues. By applying slight pressure and analysing how  tissue deforms in response, elastography can help in identifying lesions or abnormalities.

Artificial Intelligence

Artificial Intelligence (AI) can enhance the diagnostic process of endometriosis via transvaginal ultrasound (TVUS) by enabling more accurate analysis of imaging data. AI algorithms can be trained to recognize specific patterns and markers indicative of endometriosis, which may not be easily discernible by the human eye. This can help in identifying the presence and extent of endometriosis with greater precision, supporting sonographers in making more informed decisions and potentially leading to earlier detection and treatment of the condition. However, don’t worry, AI won’t be replacing sonographers any time soon. 

This advancement in imaging technology enhances diagnostic precision and also significantly improves the overall management of endometriosis. By offering a less invasive diagnostic option, TVUS minimises patient discomfort and anxiety, allowing for a smoother journey through endometriosis diagnosis and treatment.

Reference

• Deslandes, A., Panuccio, C., Avery, J., Condous, G., Leonardi, M., Knox, S., Chen, H., Hull, M. 2024. Are sonographers the future ‘gold standard’ in the diagnosis of endometriosis? Sonography. https://doi.org/10.1002/sono.12402

Bibliography

• SonoPODography: A new diagnostic technique for visualizing superficial endometriosis. https://pubmed.ncbi.nlm.nih.gov/32961428/
• Superficial Endometriosis at Ultrasound Examination—A Diagnostic Criteria Proposal https://www.mdpi.com/2075-4418/13/11/1876 

====================

Content Disclaimer

The information provided on this website is for educational and informational purposes only. It is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your obstetric doctor or other qualified provider with any questions you may have regarding a medical condition or treatment and before undertaking a new healthcare regimen. 

The content on this website is not intended to be a comprehensive source of information on any particular topic and should not be relied upon as such. The authors and publishers of this website are not liable for any damages or injury resulting from the use or misuse of the information provided on this website.