There are so many other signs of Endometriosis that can be looked for in the female pelvis and you can start with the next pelvic assessment you do! Plus links to some great YouTube videos for visuals on what these lesser-known signs are and where to find them.
However, there are many other findings that we can assess for that also indicate endometriosis, especially in the absence of a big obvious complex cyst. These are a few of the things that I have learned from my research, and personal experience, that I wanted to share with you to make identifying the signs of endometriosis easier:
1. Asking the right questions. The most frequent female pelvic requisition that I get is for pain. Pelvic pain, menstrual pain, chronic lower abdominal pain, etc…. Without more information it would be easy to just do a quick transabdominal assessment looking for anything big and obvious, and then send the patient on their way. However, with a few simple questions to understand more about their pain, you'll easily be able to determine if endometriosis is a possible cause.
Questions such as how long the pain has lasted, how intense it is, if it has prevented them from going to work or attending school, if they have a change in bowel habits (constipation or diarrhea) or recurrent UTIs around their period, if intercourse is painful, if they've had infertility problems...
You get the point. Any question relating to the wide range of endometriosis symptoms that I listed in Part 1 will give you valuable information to help your patient find the cause of her pain.
2. Assessing with the best method. The best way to assess for signs of endometriosis is with a transvaginal (TV) or endovaginal (EV) ultrasound. Many endometriomas are very small and cannot be identified transabdominally.
If these nodules are missed, that woman could suffer for many more years before being sent for another ultrasound. Don't be the reason that she takes 6 - 12 years to be diagnosed! Take the time to always do the EV scan and be thorough.
3. Finding adhesions. Endometriosis often causes adhesions between the cervix or uterus, and adjacent bowel wall or bladder wall. Adhesions can also cause immobility of the ovaries next to the uterine body.
The best way, and a very easy way, to assess for this is by using the end of the EV probe to gently but firmly press along the cervix and uterus into the Pouch of Douglas (the area behind the uterus, also known as the posterior cul-de-sac), and around both ovaries, to check for a lack of sliding past adjacent tissues which indicates adhesion and is therefore suspicious for endometriosis.
4. Locating nodules. Endometriosis can also form nodules or hypoechoic, heterogenous areas of thickening in three main spots in the pelvis. The posterior vaginal wall, the posterior bladder wall and bowel walls adjacent to the uterus. These can be subtle, but are very important indications of the disease, especially of the more difficult to diagnose deep-infiltrating endometriosis (DIE).
Nodules in these areas can be easily assessed by placing the EV probe into the posterior fornix to see the vaginal wall, the anterior fornix to see the bladder wall and in both the left and right fornix to see bowel walls. Using these pockets around the cervix (aka fornices) require only very slight modifications to the usual camera angles but provide a view into areas that would otherwise not get adequate attention.
5. Two final hints. If the uterus is fixed in one position throughout the EV scan, with an anteverted cervix and a retroflexed uterine body, and if there is adenomyosis present (a noticeably thickened area of myometrium with streaky shadowing), this is highly suspicious for the presence of endometriosis. A thorough assessment of the pelvis should be done for any indication of nodules, adhesions or complex cysts.
A normal uterus should be mobile and non-tender. It should change position slightly while you are scanning, not remain fixed in an unnatural position the whole time. It should also not cause intense pain to be scanned endovaginally – these are both signs that endometriosis may be present and should prompt you to assess very thoroughly in search of any other signs of complex cysts, nodules or thickened walls.
If you are interested in learning more about what to look for when assessing the pelvis for endometriosis there are some great videos on YouTube that I highly recommend.
--> How to do a Detailed Ultrasound for Endometriosis - https://www.youtube.com/watch?v=F8XQxEzmE1I
--> Subtle Endometriosis Findings - https://www.youtube.com/watch?v=GNlbV3U9Eoc
Thanks for taking the time to read about this interesting topic. I hope that the next time you have a female patient with a requisition that says PAIN, these tips help you to do the best assessment possible.