Ultrasound could diagnose endometriosis earlier and avert surgery

Jasmin Teurlings’ story is not uncommon.
 
She started experiencing symptoms of endometriosis at 16, but was not diagnosed until the age of 21, having been convinced by medical specialists that it was ‘all in her head’.
 
‘My mother had previously been diagnosed with endometriosis so recognised the signs and was very quick to act,’ Ms Teurlings said.
 
‘Despite those symptoms and my family history, the first gynaecologist I saw said I was too young to have endometriosis.’
 
Ms Teurlings is one of around 700,000 women in Australia who live with the chronic gynaecological condition.
 
Laparoscopic surgery is currently the gold standard for diagnosing the three types of endometriosis – peritoneal, ovarian and deep-infiltrating. But this procedure is invasive, comes with risks, delays, and sometimes even proves to be unnecessary.
 
But Alison Deslandes, a specialist obstetrics and gynaecological sonographer and researcher at the University of South Australia, told newsGP that transvaginal ultrasound (TVUS) could help women get an earlier diagnosis and, in some cases, avoid the costly procedure altogether.
 
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.
 
‘Generally, we can be pretty confident that if the scan is done well, ovarian disease – the endometriomas and the deep disease, which is where the deposits penetrate further than five millimetres beneath the peritoneum – should be seen,’ she said.
 
‘Accuracies are up over 90% for that.’
 
Dr Amy Moten, GP and Chair of the RACGP Specific Interests Sexual Health network, told newsGP that, in line with the NICE guidelines, ‘a good quality TVUS should always be part of the diagnostic work up’ of symptoms suggestive of endometriosis.
 
‘Although laparoscopy is the gold standard for diagnosing endometriosis, it is not always practical or available. People may have to travel from rural areas or spend a long time on public waiting lists to access laparoscopy,’ she said.
 
‘There is also increasing support for reducing the lifetime number of surgeries for people with endometriosis as scarring and other complications can occur.’
 
Endometriosis occurs when endometrial tissue grows outside of the uterus, forming legions on the ovaries, bowel and pelvis, and sometimes even spreads to other organs. 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.
 
‘Previous misconceptions by patients and health professionals include the idea that all period pain is normal, and that people will grow out of it, or it will go away after having a baby,’ she said.
 
‘Also, as people are generally reluctant to talk about their periods, they may not know what is abnormal and when to ask for help.
 
‘GPs should include a brief discussion of periods as part of any routine check-up in people who are menstruating, particularly young people.’
 
In some cases, however, endometriosis can have no symptoms at all, and is sometimes only discovered when women are struggling to conceive.
 
‘The evidence says that up to 50% of women with infertility will have endometriosis as well, so it’s incredibly common in that group,’ Ms Deslandes said.
 
‘But those are the people I tend to see where there’s significant nodular disease but their symptoms haven’t ever been that bad that they thought to do anything about them.
 
‘That’s one of the mysteries of endometriosis. We sometimes see women that have the absolute worst nodular disease and the worst-looking disease that has almost zero symptoms, versus the woman that has one or two little superficial lesions that can barely leave the house she’s in so much pain.
 
‘It seems nonsensical, but that unfortunately is endometriosis.’


Alison Deslandes led a systematic review of 35 articles that found transvaginal ultrasound can be a valuable and accurate diagnostic tool for deep-infiltrating endometriosis.

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.
 
While patients who are referred to a radiology clinic, Ms Deslandes says that some sonographers may only look at the uterus and ovaries, missing the posterior compartment and other areas where endometriosis is often seen.
 
To gain further insight, she is currently investigating whether TVUS is as accurate when performed by generalist sonographers and, if so, if they could perform the procedure in an outpatient facility to make it more accessible.
 
‘Anecdotally and from the preliminary results that we’ve got so far, it looks like [sonographers are] actually pretty good and that people can be quite confident,’ Ms Deslandes said.

‘This would reduce diagnostic delays and give women with [deep-infiltrating endometriosis] a non-invasive, yet highly accurate diagnostic test.’

But TVUS is only one piece of the puzzle. It cannot rule out endometriosis 100%.
 
‘What we tell our patients is that if the scan is negative that we’ve essentially ruled out deep or ovarian disease for them or, crudely speaking, stage three or stage four disease,’ Ms Deslandes said.

‘But we haven’t necessarily ruled out stage one and stage two. So there’s a good 50% of people that would probably have endometriosis that would have a negative scan, even if that scan’s done really well.
 
‘So it’s very important from a management point of view that their clinician still consider laparoscopy if their symptoms are bad enough to warrant that.’
 
As GPs are often the first port of call for people experiencing pelvic pain or menstrual issues, Dr Moten said GPs are well-placed to pick up on the condition and make a timely diagnosis.
 
‘When endometriosis is detected and treated early, it can avoid years of pain for sufferers, as well as reducing long-term complications such as chronic pelvic pain and infertility,’ she said.
 
‘This life-changing intervention should not be delayed because of poor access to laparoscopy when the diagnosis can be made by GPs with the appropriate tools such as ultrasound.’
 
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endometriosis laparoscopy transvaginal ultrasound women’s health