Old Tool, New Tricks: The Power of Ultrasound

Author: Jennifer Jaggi MD

“I never knew you could see all that on ultrasound!”  It’s something we hear often when patients get an ultrasound as part of their initial consult.  Many of them have already had multiple ultrasounds, and been told repeatedly that things looked “normal” or “unremarkable.”  And so they are shocked when there are multiple findings to suggest endometriosis.  The truth is, I was initially surprised by all of these findings too. 

When I started as a fellow at Pacific Endometriosis and Pelvic Surgery about 6 months ago, it was after working almost 10 years as a general OB/GYN.  I was relatively familiar with transvaginal ultrasound, but primarily to assess for early pregnancy and its complications.  Now as a fellow, I’ve learned to routinely do a transvaginal ultrasound as part of all new consults for pelvic pain, and that it essentially serves as an extension of the exam.  The first routine part of the ultrasound is evaluating the uterus and adnexa (a fancy word for the ovaries and fallopian tubes) including looking for fibroids and ovarian cysts.  The next steps – which are not as routine – include looking for mobility between structures, checking for tenderness in areas commonly affected by endometriosis, and assessing the rectosigmoid (the most common site of bowel endometriosis) for lesions.  The lack of mobility between structures – such as between the ovaries and sidewall, or cervix and rectum – can be a sign of adhesions caused by endometriosis.

What I’ve come to realize is that a sensitive ultrasound for endometriosis is one that is dynamic, with findings made in real time, while the patient is on the exam table.  But the reality is that most pelvic ultrasounds aren’t approached this way.  Typically a pelvic US is ordered by a provider in the office or in the ED, the images taken by a tech in the radiology area, and then later read by a radiologist who writes the report.  The problem with this is that the dynamic part of the ultrasound is not captured.  And the final report may be “unremarkable” simply because the uterus and ovaries were a normal size.  But not mentioned are whether the ovaries are adherent, the cervix is tethered to the rectum, or the uterosacrals are tender. 

So back to a question that often comes up…  “Can endometriosis be diagnosed on ultrasound?”  Technically, no, unless a definite endometrioma or rectal nodule of endometriosis is seen.  The gold standard for diagnosing endometriosis is still laparoscopy with histology for diagnosis.  Yet I’ve learned that a thorough ultrasound can make us highly suspicious for endometriosis.  It allows us to better counsel patients about the extent or stage of endometriosis they may have.  And when surgery is planned, it prepares us for the complexity of the case.  How much dissection will be entailed, how long the case may go, and whether to have a general surgeon on standby. 

In medicine, the analogy of a physician’s toolbox often comes up.  In this case, I feel like my toolbox has expanded, but actually my physical tools have not changed at all.  I’ve just started to learn to use one important tool in a much more nuanced way.  So as far as sayings go, maybe there’s hope for an old dog after all.