Endometriosis is a serious gynecological disease that is asymptomatic in its early stages. Pathology is characterized by the proliferation of the mucous layer of the uterus (endometrium), while the lesions extend throughout the abdominal cavity, making it difficult for normal vital organs and systems to function. With early diagnosis and timely treatment, it is possible to prevent the development of serious complications, to preserve female reproductive functions.
First of all, the patient should be alerted by long and painful menstruation, bleeding between cycles, painful sensations during sex. These are the first signs that may indicate the presence of endometriosis. With these symptoms, a woman should immediately contact a gynecologist. It is important to undergo a comprehensive examination using the necessary diagnostic methods.
Ultrasound examination is appointed first, but whether endometriosis can be seen on the monitor is a moot point. In the early stages of the pathology in the reproductive organs there are practically no structural changes. Therefore, an accurate diagnosis can be made only after a full examination. If you suspect the development of pathology, when doing an ultrasound - a doctor must determine, since the changes in the endometrium during the cycle affect the results of the examination.
Ultrasound as a method for the diagnosis of endometriosis
Ultrasound is one of the primary methods of diagnosis of endometriosis, which allows to confirm the preliminary diagnosis, which was made on the basis of examination by a gynecologist. Ultrasound diagnostics gives a complete picture of the state of the pelvic organs, and also allows early detection of pathological processes in the muscle and mucous membrane of the uterus.
An ultrasound examination is prescribed by a doctor if the patient has symptoms such as:
- pain in the lower abdomen and lower back, which tend to increase during menstruation,
- the presence of spotting between periods,
- an increase in the period of menstruation and the amount of discharge,
- long absence of pregnancy.
Ultrasound diagnosis for suspected development of the disease is carried out in two ways: transabdominal and transvaginal. The first involves the study directly through the anterior abdominal wall, the second - the introduction into the vagina of a special sensor. For ultrasound diagnostics of endometriosis, transvaginal method does not require any preliminary preparations. Transabdominal examination is usually carried out with a filled bladder, so 2 hours before the procedure you need to drink about a liter of water and not go to the toilet.
On which day of the cycle it is better to do ultrasound for endometriosis - the doctor must determine. Pathology develops in the inner layer of the uterus (endometrium), which, during menstruation, is rejected and transported monthly from the female body. Immediately after menstruation, the thickness of the endometrium is only 2–5 mm, in the middle of the cycle it increases to 9–13 mm, and the second half is compacted to 20 mm. It is recommended to do a scan no earlier than a week after the end of menstruation. But since every day the endometrium is compacted and becomes thicker, when it is in your case that an ultrasound scan can be performed only by the attending physician.
Many gynecologists agree that the diagnosis of endometriosis of the uterus will have more reliable results in the second half of the menstrual cycle (by day it is 14-20 days). It was at this time that the echogenicity of the pathological foci is enhanced, which simplifies their detection.
Is endometriosis visible on ultrasound? During the diagnosis, the doctor examines the following parameters:
- dimensions of the reproductive organ,
- external contour of the uterus,
- punctate structure of internal tissues,
- echogenicity of the muscular layer of the uterus and its cavity,
- changes in the cervix and fallopian tubes,
- appendage condition
- nodular seals.
Uneven and unclear contour of the uterus indicates the presence of a pathological process. In a healthy woman, the normal parameters of the uterus are as follows:
- length - 7 cm
- width - 6 cm
- thickness - 42 mm.
Deviations from these parameters indicate the presence of a pathological process. With endometriosis, uneven thickening of the uterine walls is clearly visible. Look like pathological lesions, and the modified structure of the uterus, look at the photo.
Normally, the endometrial echogenicity is uniform, uniform, and the uterus should have a uniform structure and smooth edges. Detection on ultrasound hyperechoic structures indicates the presence of endometriosis. Changes in the structure of the cervical canal and the cervix itself, which normally has a length of 4 cm and a uniform echostructure, can also indicate the presence of the disease. Ultrasound can see all abnormalities.
Echo signs of endometriosis:
- changing the structure, shape, size of the uterus and its appendages,
- increased density and thickening of the walls of the body,
- the presence of nodules and cystic formations on the mucous membrane.
Using ultrasound to determine the localization of pathological foci. The most common form is ovarian endometriosis. Ultrasound can detect polyps and cysts of endometrial origin, determine their structure and size. This is important in cases where differential diagnosis is performed. Due to the structural similarity of endometrial neoplasms with luteal and hemorrhagic cysts, it is often difficult to make an accurate diagnosis.
It should be noted that despite the high efficiency of the ultrasound diagnostic method, endometriosis on ultrasound examination is not always possible, especially if there are small foci located in the deeper layers of the muscle tissue of the organ. Therefore, the results of ultrasound studies are not an absolute confirmation of the absence of pathology.
To clarify the diagnosis, a woman should undergo a comprehensive examination using instrumental and laboratory diagnostics. Patients with a diagnosis of endometriosis during treatment should be systematically examined by ultrasound, this allows us to evaluate the effectiveness of the therapy. In order to prevent each woman is recommended to regularly visit the antenatal clinic.
Diagnosis of endometriosis on ultrasound
The simplest and safest method for determining women's gynecological pathology is ultrasound examination of endometriosis of the uterus. But right away it should be noted that this is not the most accurate diagnostic method and the answers to all questions concerning this disease, it can not always give. Therefore, in some cases, additional diagnostic procedures are prescribed.
The optimal time for ultrasound examination
To determine which ultrasound for endometriosis, on what day to do, it is necessary to take into account changes in the endometrium throughout the cycle. So, on the first day he rejects, causing the onset of menstruation. And after the menstrual bleeding is over, the endometrial tissues become thinnest. Based on this, after three to five days after menstruation, it is impractical to do a survey, since the lesions in this period are very small and it is very difficult to detect them. The best option when endometriosis can be seen on ultrasound is best - it is before menstrual bleeding, that is, at 23-25 days of the female cycle. At this time, the endometrium is the most thick and endometriotic pathological formations are best viewed.
Indications for ultrasound
The examination is based on the following clinical picture:
- The pain syndrome that occurs periodically or is of a regular nature, localized in the lower abdomen, which is especially acute when menstruation occurs.
- Disorders of the menstrual cycle.
- The presence between the monthly discharge luminous nature, having a darker color compared with uterine bleeding during menstruation.
- Failure to conceive.
No preparation procedure requires. The only thing to consider is to determine more accurately endometriosis: an ultrasound scan on which day of the cycle to do.
There are two methods of diagnosis:
- Transvaginal, performed using a sensor inserted into the vagina, reading the image of the necessary internal organs. The bladder must be empty during the procedure.
- Transabdominal, characterized by research through the peritoneal wall. Before the procedure to improve the contact of the skin and the sensor of the apparatus, the lower abdomen is smeared with a special gel. This examination, unlike the previous one, is done with a full bladder.
- On pelvic ultrasound, endometriosis can be detected after evaluating such indicators as the size of the uterus and the condition of its external outlines, the structure and size of the cervix, echostructure of the myometrium, contours and the state of the ovaries.
Ultrasound signs indicating endometriosis
The signs of endometriosis on ultrasound are as follows:
- Fuzzy outlines and unevenness of the endometrium.
- Asymmetry of uterine walls, their thickening.
- Hyperechoic formations of the muscular uterine layer.
- Punctate heterogeneous structure of ovarian tissue.
- Resizing the uterus upwards.
- The presence of pathological foci of various types, nodular structures.
- Expansion of the cervix and uterine canal and change their structure.
Diffuse form of endometriosis of the uterus (adenomyosis) on ultrasound
Use a convex sensor 3.5-7 MHz. The position of the patient lying on his back. Bladder different degrees of filling. Smoothly reduce the intensity of the echo-positive component of the image: many elements of the picture disappear, but high-density pathological details of the image are highlighted against a general dark background. Repeated implementation of this technique in various angles provides reliable visualization of heterotopies, the dimensions of which exceed 3-4 mm.
On ultrasound, the uterus is diffusely enlarged, the shape is spherical, the contour is clear and even. In comparison with the cervix, the echogenicity of the uterus is increased, the myometrium is heterogeneous due to the multitude of hyperechoic point and linear inclusions, the blood flow is often diffusely strengthened. With TV ultrasound in the peripheral parts of the uterine wall, convoluted dilated vessels are often seen. In half the cases, the endometrium is thicker than normal. In young patients, the echogenicity and echostructure of the uterus are more often normal, but the uterus is always spherical.
"God in the little things"
The size of the uterus can be increased in tall women who have given birth to many, before menstruation, with an intrauterine contraceptive. Unlike endometriosis, the uterus remains oval or pear-shaped, and the density of the myometrium is regarded as low.
With a pronounced bend, the size of the uterus can be more than normal, and the shape can approach the spherical. In such cases, the absence of a diffuse increase in echogenicity of the myometrium, endometrial hyperplasia, and complaints is important.
Before menstruation, the echogenicity of the uterus may decrease due to vasodilation and edema.
Diffuse fibrous changes of myometrium in adenomyosis are often mistakenly regarded as diffuse fibromatosis of the uterus.
Table. The difference between adenomyosis and diffuse forms of uterine fibroids.
The local form of endometriosis of the uterine body on ultrasound
Separate bright hyperechoic inclusions without acoustic shade, irregular round, oval, or clumpy shape, size 2-6 mm, are found in the myometrium. These are areas of fibrosis around one or more endometriomas in the thickness of the myometrium. While cyclic processes occur in foci, they may increase in size to take the form of small, well-defined, irregularly shaped nodes. With the local form of endometriosis, the uterus is of normal size and typical form, the endometrium is not changed.
In almost all such cases, habitual overdiagnosis of intramural fibromatous nodes with a prevalence of fibrosis and calcification takes place. Note that a clear dependence of the lesion on the phase of the cycle indicates local nodular endometriosis.
Uterus cervical endometriosis on ultrasound
Endometriosis of the cervix is rare and does not give pronounced manifestations. The only complaints may be bleeding before and after menstruation.
On ultrasound in the myometrium of the cervix determine cysts or cervical area is thickened compared with the intact departments. The outer contour in this place is clear, even or wavy. The echogenicity of cysts free myometrium is not changed. The configuration of the neck is club-shaped, pear-shaped or spindle-shaped. Cysts are rounded, the wall is hyperechoic thin, the gain effect is behind, the content is uniform or fine, the size is 4-15 mm. Especially clearly visible TV sensor.
In the cervix much more often than endometroids are found Nabot cyst. With a long-existing glandular pseudo-erosion, the stratified squamous epithelium of the vaginal part of the cervix overlaps the mouths of the glands, which leads to the formation of thin-walled cavities. Nabot cysts are asymptomatic, very slowly increasing in size to 15-20 mm, and then emptied, the contents are a colorless, sterile, cell-free liquid. On ultrasound, Nabot's cysts are located superficially, without thickening of the wall and deformation of the contour; long-existing cysts are immersed in the myometrium.
Ovarian Endometriosis on Ultrasound
Ovarian endometriosis is represented by two forms - endometrial cysts and superficial endometriosis.
Endometriotic cysts can reach large sizes (up to 10-15 cm in diameter). On the smooth inner surface there are seals, which under microscopic examination turn out to be areas of the endometrium, the contents of chocolate color. On ultrasound, a round contour with a double contour is determined, the capsule in 30% of cases contains hyperechoic foci, there are no dense inclusions in the lumen, the contents are hypoechoic homogeneous, there is no internal blood flow. The echo structure does not change at different periods of the menstrual cycle.
On ultrasound in case of superficial endometriosis, a small (2-9 mm) hyperechoic formation of a round, oval or glybchaty shape is determined on the capsule of the ovary, the contour is clear, even or spiculo-like due to single short fibrous cords. The structure is homogeneous, echo high or very high. In the area of the lesion, there is some retraction of the contour of the ovary, the endometrioma is partially immersed in the ovarian tissue, but is always clearly limited from it by a thickened and packed capsule. With purely commissural changes, paraovarially, the most typical are multiple linear hyperechoic inclusions along the edge of the ovary without contour retraction.
Most of these patients are observed and treated for adnexitis, and the possibility of endometrial damage to the ovary capsule is not taken into account. Long-existing, untreated endometriosis of the ovary often leads to adhesions in the pelvis, which creates the conditions for chronic salpingitis. It is necessary to look for hydrosalpinx / hematosalpinx and peritoneal cysts - indirect signs of adhesions in the pelvis.
Picture. Diffuse paraovarian fibrosis, as a result of external endometriosis.
Picture. Under the influence of hormone therapy, the lesions are reduced and can even dissolve.
Endometriosis of the fallopian tubes, outer wall, round and wide ligaments of the uterus is not visible on ultrasound.
Endometriosis of ovarian ligaments on ultrasound
Optimally, the TA-ultrasound with a filled bladder, then the ovaries are pushed upward, the ligaments are stretched and fully fall into the image. With a TV ultrasound, the ovaries descend on the empty bladder, the ligaments hang and are almost upright in relation to the vaginal arches, transverse and oblique sections of the ligaments enter the image, which merge with the surrounding tissues.
On ultrasound, endometriosis of the ovarian ligaments is a hyperechoic nodule or a large linear spike up to 30-32 mm in a sleeve-like manner encompasses the ligament.
Deep infiltrating endometriosis on ultrasound
TV ultrasound has a clear advantage over TA ultrasound. When examining the bladder slightly filled. It is necessary to determine the number, position, size (in three planes) of endometriomas, echostructure.
Four stages of TV ultrasound for suspected deep infiltrating endometriosis:
- Examination of the uterus and ovaries. Rate the mobility of the uterus - normal, low, fixed ("question mark"),
- Indirect signs of endometriosis: local pain and fixed ovaries increase the likelihood of endometriosis and adhesions. By applying pressure between the uterus and the ovary, it can be assessed if the ovary attaches to the uterus medially, to the side wall of the pelvis in the lateral direction, or to the ligaments.
- Rate Douglas space using a "sliding sign" with dynamic TV ultrasound. When the uterus is in anteversion, soft pressure is applied to the cervix using a transvaginal probe, and the rectum slides freely along the posterior surface of the cervix (retrocervical area) and the posterior wall of the vagina. Затем ставят одну руку на переднюю брюшную стенку для движения матки между пальпирующей рукой и трансвагинальным зондом, чтобы оценить, как передняя стенка кишки скользит по задней поверхности верхняя часть матки и дно.When a sliding mark is considered positive in both of these anatomical areas (retrocervix and the back wall of the uterus) it is recorded that the Douglas space is not obliterated.
- Evaluate anterior and posterior cervical space.
Nodular form - hyperechoic compactly arranged heterotopies soldered to each other in the space between the posterior surface of the cervix (or isthmus) and the anterior wall of the rectum. The shape of the hearth is irregular oval, less often irregular round or blocky. The contours are uneven (bumpy) and hard. The contours of the contours - the consequences of adhesions and local infiltrative distribution of endometriosis. The sizes of the center from 3 to 30 mm. Posterior endometriosis is characterized by very high density, often with an acoustic shadow.
Picture. Heterotopy group
Cicatricial-infiltrative form is characterized by a significant predominance of the connective tissue component. In other words, a minor endometrial lesion initiates the development of pronounced adhesions. Distribution of changes goes along the posterior wall of the cervix: vaginal fornix, sacro-uterine ligaments, peritoneum covering the uterus, wide uterine ligament and uterine wall, anterior wall of the rectum, bladder and ureters. On ultrasound, hyperechoic heterogeneous compaction of an elongated shape - cicatricial tension - creeping along the back wall of the cervix, the anatomical and topographical features of which determine the position and shape of the modified area. The pathological focus forms a flat platform - straightening of the cervix at the level of the posterior side of the lesion. Heavy contours. Heavyness (spiculobraznosti) - is a reliable indicator of locally-invasive growth.
Picture. Perifocal inflammation appears before menstruation or immediately after their termination - hyperechoic focus is outlined with a hypoechoic rim. Perifocal inflammation is a constant companion of all variants of endometriosis, but only with lateral localization can be seen with TV ultrasound.
Sacro-uterine ligaments - from the posterior-lateral surfaces of the cervix and isthmus, are one of the objects of dissemination of posterior endometriosis; they arch the rectum and attach themselves to the pelvic fascia of the sacrum. An isolated lesion is rare, often secondary lesions due to ingrowth from the lateral transverse-uterine-rectal depression. With ultrasound, the sacro-uterine ligaments are not visible. A survey ultrasound is used with a weakly filled bladder, vigorous compression of the anterior abdominal wall, the beam is directed toward the intended focus — a rounded hyperechoic formation of one of the parametric regions at the level of the isthmus. In such patients, cicatricial-infiltrative changes often go to the back wall of the bladder, sometimes to one of the ureters - narrowing, ureteroectosis, hydronephrosis.
Indirect signs of endometriosis invasion into the rectum are large knot sizes, pronounced lower edge + pain during defecation, aggravated during menstruation, blood in feces during menstruation.
The ovarian “kissing” sign indicates the presence of serious pelvic adhesions. Endometriosis of the intestine and fallopian tube is much more common in women with kisses of the ovaries against those who have no kissing ovaries.
Anterior cervical space on ultrasound
Assess the anterior cervical space where the bladder, the anterior wall of the uterus and the ureters are located.
We must not forget that the TA-ultrasound and TV-ultrasound are complementary techniques, in the form of a two-stage study are a powerful diagnostic tool for the diagnosis of endometriosis.
It is best to scan the bladder if it contains a small amount of urine. Four zones of the bladder on ultrasound:
- (I) in the trigonal area, which is within 3 cm of the urethral opening, the smooth triangular area is divided into two ureteral openings and the internal opening of the urethra,
- (Ii) at the base of the bladder, which faces back and down and lies next to both the vagina and the supravaginal uterus,
- (Iii) the bladder dome, which lies beyond the base and is intra-abdominal,
- (Iv) extraabdominal bladder.
Endometriosis of the bladder is more common in the base and the dome of the bladder than on the peritoneal surface of the bladder. On ultrasound, endometriosis in the anterior region can be diverse, including hypoechoic linear or spherical lesions, with or without clear contours involving the muscles (most often) or the (sub) bladder mucosa. Endometriosis of the bladder is diagnosed only if the muscles of the wall of the bladder are damaged, lesions involving only the serous membrane are a superficial disease.
Picture. The four zones of the bladder: the trine, the base of the bladder, the dome of the bladder and the extra-abdominal bladder. The point of demarcation between the base and the dome is the bladder-uterine bag.
Obliteration of the uterine cystic region can be assessed using a “sliding” trait, i.e., a transvaginal probe is installed in the anterior vault and the uterus moves between the probe and the operator's one hand placed in the suprapubic region. If the posterior wall of the bladder slides freely on the anterior wall of the uterus, then the uterine area is not obliterated. If the bladder does not freely slide along the anterior wall of the uterus, one may think about obliteration of the uterine cystic region by adhesions. Adhesions in the front of the pelvis are present in almost a third of women after cesarean section and not necessarily a sign of endometriosis.
Distal ureters should be examined. The ureter can be found by identifying the urethra in the sagittal plane and moving the probe to the side wall of the pelvis. The intravesical segment of the ureter is determined and its course follows where it leaves the bladder and further to the side wall of the pelvis and to the level of the bifurcation of the common iliac artery. This is useful to see how peristalsis occurs, as this confirms the patency of the ureters.
On ultrasound, the ureters usually look like long tubular hypoechoic structures, with a thick hyperechoic wall extending from the lateral surface of the bladder, from the base to the common iliac vessels. Dilatation of the ureter due to endometriosis is caused by a stricture (either external compression or internal penetration) and the distance from the distal opening of the ureters to the stricture should be measured. All women with deep endometriosis examine the kidneys to eliminate hydronephrosis, as a result of obstruction by endometriosis.
Rear cervical space on ultrasound
The most common localizations of endometriosis in the posterior sections are the uterosacral ligaments, the posterior vaginal fornix, the anterior wall of the rectum / anterior rectosigmoid junction and the sigmoid colon, the rectovaginal septum. On ultrasound, endometriosis in the posterior cervical space appears as a hypoechoic thickening of the intestinal wall or vagina, or as solid hypoechoic nodules that may vary in size and have even or irregular contours. Hypoechoic nodules may be homogeneous or heterogeneous with or without large cystic areas, and there may not be cystic areas adjacent to the nodes.
Deep endometriosis of the rectovaginal septum (hyperechoic layer between the vagina and rectum) is confirmed by TV ultrasound. Isolated endometriosis PB septum is rare, often germination in the vagina and / or rectum. On TV ultrasound, the lesion is visible on the PB space below the line running along the lower border of the back lip of the cervix (under the peritoneum).
Picture. Retrofrontsintsnyh implants (65%) is usually a small lesion that develops from the posterior chest to the rectovaginal septum, but not through it. Hourglass-shaped implants (25%) are larger lesions (> 3 cm), which originate from the retropharnital position and extend to the anterior rectal wall. And the rectal-vaginal septum grafts (10%) are usually a small lesion, separated from the cervix, located under the peritoneal fold of the Douglas dead end.
Damage to the posterior vaginal wall of the vaginal fornix and / or the lateral fornix of the vagina should be suspected when the nodule is seen with a TV ultrasound in the rectum into the space below the line running along the caudal end of the peritoneum of the lower edge of the rectum and above the line running along the bottom borders of the posterior lip of the cervix (under the peritoneum). The posterior vaginal fornix or vaginal endometriosis is suspected if the posterior vaginal fornix thickens or if the hypoechoic layers of the vaginal wall are detected.
The obliteration of the Douglas space can be assessed as partial or full depending on whether one side (left or right) or both sides, respectively, show a negative sliding sign.
Normal sacro-uterine ligaments, as a rule, is not visible on ultrasound. Endometriosis sacro-uterine ligaments can be seen in the mid-sagittal section of the uterus. However, this is best seen by placing the transvaginal probe in the posterior vaginal fornix in the midline in the sagittal plane, and then moving the probe. On ultrasound hypoechoic thickening with clear or fuzzy boundaries is considered abdominal fat around the sacro-uterine ligaments. The lesion may be isolated or may be part of a large nodule that expands into the vagina or into other surrounding structures.
Deep endometriosis with intestinal lesions includes the anterior wall of the rectum, the rectosigmoid junction and / or the sigmoid colon, which can be visualized using TV ultrasound. Moutte take the form of an isolated lesion or may be multifocal (multiple lesions of one segment) and / or multicentric (multiple lesions affecting several segments of the intestine, i.e. small intestine, colon, cecum, ileocecal connection and / or application).
Histologically, intestinal endometriosis is defined as the presence of endometrial glands and stroma in the intestinal wall, reaching at least the muscle layer, where it invariably causes smooth muscle hyperplasia and fibrosis. This leads to a thickening of the intestinal wall and some narrowing of the intestinal lumen. Normal wall layers can be visualized on a TV US: serosa rectum is visible as a thin hyperechoic line lamina muscularis is hypoechoic, longitudinal smooth muscle (external) and circular smooth muscle (Internal) separated faint thin hyperechoic line submucosa is hyperechoic , and the mucous membrane is hypoechoic.
Endometriosis of the intestine is seen as a thickening, hypoechoic muscular wall or as hypoechoic nodules, with or without hyperechoic foci with blurred edges. The size of these foci may vary.
Intestinal lesions can be described according to the segment of the rectum or colon in which they occur. Lesions located below the level of the USLs insertion on the cervix are denoted as lower (retroperitoneal) in front of the rectum, above this level denoted as the upper (visible during laparoscopy) anterior wall of the intestine, at the level of the uterus, denoted as lesions of the rectum, and those above the level of the uterus are denoted as lesions of the anterior sigmoid. The distance between the lower edge of the most caudal lesion and the anal face should be measured. You can measure the distance from the anus to the intestinal lesion using transrectal sonography.
Hourglass-shaped nodules occur when damage to the posterior vaginal fornix expands and extends into the anterior wall of the rectum. On ultrasound, the part of the DIE lesion located on the anterior rectal wall is the same size as the part located in the posterior vaginal vault. There is a small but easily visible connection between these two parts of the lesion. These lesions are located below the peritoneum and Douglas spaces and are usually large (3 cm on average).
Endometriomas can undergo decidualization during pregnancy, in which case they can be confused with malignant tumors of the ovaries with ultrasound. The simultaneous presence of other endometriotic lesions can facilitate the correct diagnosis of endometriomas during pregnancy and minimize the risk of unnecessary surgery.
Take care of yourself, Your Diagnostician!
Who is at risk?
Endometriosis is a polyetiological disease. There are several theories of the origin of foci of endometriosis, the main of which are transport and fetal.
Based on these theories, one can identify the main causes of endometriosis.
Displacement during prenatal development of areas of material from which the uterus is formed.
- Casting of endometrial cells that were rejected during menstruation into the abdominal cavity.
- Endometrial cell movement during uterine surgery.
- Lymphogenous distribution of endometrial cells.
Implantation and growth of endometrial cells outside the uterine mucosa occurs against the background of hormonal and immune dysfunctions.
The main risk factors for developing the disease are highlighted.
- Heredity (endometriosis in the mother, the sister).
- Immune and hormonal imbalance.
- Late onset of sex life.
- Inflammatory processes of the genital organs.
- Various manipulations on the uterus.
- Prolonged use of the Navy.
- Late onset of menses.
The first signs of endometriosis
Specialists identified the most characteristic symptoms.
Pain syndrome.As a rule, it is manifested by algodysmenorrhea. Painful sensations appear 1–2 days before menstruation, reach maximum intensity during menstruation, sometimes aching pains are noted a few more days after its completion.
- Menstrual dysfunction Menorrhagia (heavy bleeding during menstruation), metrorrhagia (bleeding from the uterus during the intermenstrual period) is noted. Metrorrhagia is manifested by scant dark bloody (sometimes brown and even black) secretions.
With severe pain during menstruation, heavy discharge, discharge outside of menstruation, you should consult a doctor and in no case do not self-medicate.
Modern diagnostic methods
Diagnosis of endometriosis is carried out on the basis of a patient survey: complaints, anamnesis (endometriosis in the immediate family, childbirth, termination of pregnancy, use of the IUD, inflammatory diseases of the genital organs).
Laboratory and instrumental methods for the diagnosis of endometriosis
- Hormonal studies.
- Ultrasound procedure.
- Magnetic resonance and computed tomography.
Hormonal studies: determination of the dynamics of the concentration of FSH, LH, progesterone, estradiol.
Manifestations of endometriosis of the uterus during ultrasound examination: echo-negative tubular structures extending from endometrium to myometrium, unevenness of the basal layer of the endometrium, small oval or rounded hypoechoic structures in the basal layer, asymmetry of the wall thickness of the uterus, an increase in its size, appearance of increased echogenicity in the myometrium, and other signs
Ultrasound signs of ovarian endometriosis:
Ultrasound signs of ovarian endometriosis:small-dotted internal structure, round shape of the formation with a double contour, the location of the education side and back from the uterus, the echo-dense capsule of the cyst, the lack of changes in the echo structure during the examination in dynamics in different periods of the menstrual cycle.
When colposcopic examination for endometriosis of the cervix are noted: pseudo-erosion with hemorrhagic contents, endometrial foci of various shapes and sizes, polyphoid foci in the region of the cervical canal.
Hysterosalpinography held on the 5-7 day of the cycle. Signs of internal endometriosis: uterine cavity of irregular triangular shape.
Laparoscopic picture of endometriosis determined by the degree of spread of the pathological focus and the duration of its existence. Modern optical technology allows you to diagnose endometriosis foci in the early stages.
MRI and CT provide an opportunity to determine the localization and nature of endometriosis. In myometrium, there are formations without clear contours, inside the pathological foci - high-intensity signals. In case of endometriosis of the ovaries, a dense capsule with uneven contours is determined.
Specialist answers to all questions on symptoms and diagnosis
- Do pains with endometriosis necessarily occur, and what kind of pains indicate endometriosis in women?
Pain in endometriosis depends on the localization of the pathological focus. Pulling pains in one side, pains when lifting weights may indicate the development of ovarian endometriosis. With endometriosis of the uterus, the pain coincides with the monthly. The intensity of pain is different: from weakly pressing or pulling to strong spasmodic.
- Can intercourse pain be a sign of endometriosis?
Yes, with endometriosis, pain may occur during intercourse.
- Какие выделения могут быть при эндометриозе у женщин?
При эндометриозе в период между месячными могут появиться кровянистые выделения темного (иногда коричневого и даже черного) цвета. Изменяются выделения и во время менструации: они становятся более обильными и более темными.
- How often should I be tested for endometriosis?
An annual routine checkup at a gynecologist is recommended for all women. In the presence of symptoms characteristic of endometriosis, it is necessary to consult a doctor as soon as possible for diagnostic studies and timely treatment.
Indications for appointment
A disease such as endometriosis cannot always be quickly identified. The fact is that in many clinical cases, it is asymptomatic. In this case, the doctor will be able to determine the pathology only with the help of ultrasound.
In this case, there are clinical signs that will be able to alert the gynecologist, as a result of which he will send the patient to undergo the above diagnostic procedure. These include the following:
- The change in the nature of menstruation: become too abundant, the color changes to dark red, or it may become brown.
- The appearance of discomfort during the implementation of sexual intercourse, urination and defecation.
- On the last or last day of the cycle, a woman experiences high-intensity pain, which stops only 2-3 days after the end of menstruation.
- A few days before the menstruation, the patient may begin to notice the appearance of smearing in her.
Signs of the disease on ultrasound
The echo signs of the course of the disease can be detected only at the second stage of its development, and it matters what day of the cycle the ultrasound study is performed. When conducting a survey at the wrong time, the doctor may get incorrect results. The choice of the day of the cycle for the diagnosis depends on the individual characteristics of the female reproductive system and which clinical signs are identified by the doctor. In many cases, the procedure is performed at the end of the menstrual cycle.
Talk about the course of uterine endometriosis can be based on the presence of the following clinical signs according to the results of ultrasound:
- a pelvic examination demonstrates an uneven thickness of the uterine walls,
- in the survey photo, the shape of the uterus changes to rounded,
- the body of the uterus looks larger in size
- diagnostics demonstrates the identification of areas with increased echogenicity and intermittent contour in the myometrium,
- overgrown endometrium can also be identified by the presence of endometriotic cysts.
If we are talking about the primary lesion of the ovaries and the appearance of cysts of this type on them, then on ultrasound it will look like an education of an echopositive type with clear edges or small strands. A double circuit will be visible on the organs due to the fact that the inclusions are separated from the main ovarian tissue.
Under the endometriotic cyst is commonly understood education, inside filled with fluid. The thickness of the cystic walls can vary significantly, due to the duration of the neoplasm. Cysts of this type do not change their position in the implementation of movements by the patient, who is being examined.
The cyst has a tendency to be localized on one side, and the ovary on it may not be visualized during the passage of an ultrasound diagnosis.
On the eve of the arrival of menstruation and during menstruation a cyst can grow.
When do you need to do research?
Medical practice shows that the best time to conduct a study of the presence of the disease in this way can be considered the second half of the monthly cycle. Of particular difficulty are clinical cases in which a woman constantly has a delay of periods, or the cycle is irregular.
It is not easy to choose the time for the examination, since the structure of the inner uterine layer undergoes modifications every few days. For this reason, in most cases for the study period, the second phase of the menstrual cycle is selected, when such changes become less pronounced. In the second phase of the monthly cycle, echo begins to grow from the edges to the center.
By the 23rd day of the cycle, the mucous membrane thickens as much as possible, the structure becomes non-uniform, the echogenicity can be characterized as high. By the 27th day the thickness of the mucous begins to gradually decrease. During the menstruation itself, hyperechogenicity is possible, which means the appearance of blood clots.
Ultrasound is considered the most effective way to diagnose such dangerous for the female reproductive system diseases as endometriosis. The definition of pathology should be carried out in an integrated manner, but the conduct of this study can most accurately determine the disease and differentiate it with other pathologies of the female reproductive system. In order to get to the study by ultrasound, you must first sign up for the initial examination by a gynecologist.
Types of disease
The external disease affects the vagina, ovaries, fallopian tubes and partially the abdominal cavity.
Internal type endometriosis directly affects the upper part of the cervix and its body.
Additionally, the disease can manifest itself in a nodular, focal and diffuse form.
Thus, the diffuse form is most often manifested in the internal type of endometriosis.
The following echo signs are indicative of diffuse type:
- round or oval body of the uterus,
- there is a thickening of the tissues that form the wall of the uterus, most often the back,
- body myometrium increased echogenicity,
- inclusions on the uterus up to 0.05 mm (calcium deposition, neoplasms of various origin, including malignant),
- The endometrium has an uneven and fuzzy contour.
With a nodal form, an ultrasound scan can show the following echo signs:
- changes in the structure of the uterine wall, most often have a round or oval shape,
- in some cases, visible education, similar to cystic, with a diameter of 30 mm,
- education itself has no clear contours
- the study may also show an endometriotic node that grows within the uterine wall (interstitial).
Focal form of the disease is manifested as follows:
- In the course of the ultrasound study, on one of the sections of the muscular wall of the uterus (myometrium), an increased echogenicity can be observed, with a lack of a clear and even contour,
- in a more detailed study, cystic masses from 2 to 15-16 mm can be detected,
- the walls of the uterus can have a different thickness compared to each other.
It is believed that to diagnose a focal or nodular form of the disease is more difficult than others. This is due to the fact that these forms have similar signs and are very rarely seen separately. Most often they can be observed in uterine myoma and diffuse lesions.
Thus, we conclude: you can identify or see signs of endometriosis with ultrasound. Today, the main part of the disease falls on the body of the uterus and ovaries.
What shows ultrasound
When a disease is detected in the uterus, first of all an ultrasound can show the following:
- roughness and blurred endometrium,
- the presence of nodal structures
- violation of the symmetry of the uterus.
Ovarian endometriosis has the following features:
- there is a formation of round shape, located on the sides or back of the uterus,
- tissue structure is heterogeneous, punctate,
- also, focal formations that have a different shape, appearance and size.
Determine the cycle for ultrasound
In order to get the most accurate results in case of suspected endometriosis, it is better to perform it on day 5, day 6 or day 7 of the menstrual cycle. It is also necessary to carry out diagnostics in case of residual spotting.
It is recommended to conduct the study several times during the following cycles. This will give more accurate results and allow you to observe the dynamics of the organ in which the disease was detected throughout the entire menstrual cycle .. If treatment was prescribed, it is approximately in the middle of the test that ultrasound should be performed to determine the effectiveness of the therapy.
When to do such an ultrasound?
We have already found out at what period it is better to diagnose endometriosis. However, many women are still wondering: when should you sign up for this study?
In fact, the answer is simple: when a woman notices signs of endomatosis.
Symptoms of endometriosis may be as follows:
- painful periods
- spotting before menstruation and after its completion,
- difficulties in conceiving a child,
- pain during sex (less often)
These signs are considered the most common. However, there are many cases where the disease is asymptomatic or the symptoms are mild. Therefore, often the disease is diagnosed already at a late stage of development. Experts recommend to undergo an ultrasound every six months - a study for the timely detection of pelvic pathologies.
Diagnosis of endometriosis with ultrasound
Diagnostics using ultrasound apparatus takes a leading role in the study of endometriosis. However, it is most effective if the disease has affected the uterus or ovaries. Diagnostics can be done in two ways:
- at first, the sensor is inserted into the vagina. This method is less pleasant, but guarantees the most effective information,
- with the second method, the study is carried out externally, i.e. through the peritoneal cavity, therefore, there are no discomfort.
Today, it is impossible to determine endometriosis with a 100% probability using ultrasound, even if the disease has affected the uterus or ovaries. Laparoscopy with additional biopsy is considered the most reliable method for determining the disease.
Signs of endometritis during ultrasound
Endometritis is a type of pelvic disease that can be detected during the study of endometriosis. They should not be confused, as they are a different pathology.
Under endometritis should be understood inflammatory process of the mucous membrane of the uterus. The cause of the disease can be mechanical damage, for example, during abortion or incorrect installation of the intrauterine device. The second cause of the disease are sexually transmitted diseases or various viruses.
Often it is possible to assume the presence of endometritis according to the patient's stories. Next, the specialist must conduct a series of procedures to establish the exact diagnosis:
- first of all, a standard gynecological examination is carried out,
- further it is necessary to take smears to establish the possible causative agent of the disease,
- and the final important step will be a study on the ultrasound machine.
It should be noted that endometritis is found in acute and chronic form. The acute form is characterized by fever, pain in the lower abdomen and the release of purulent-bloody fluid that does not apply to menstruation. ultrasound is recommended during the treatment period to control therapeutic efficacy.
The chronic form of the disease is almost unnoticed., symptomatology is not pronounced, therefore, most often the disease can be identified after an ultrasound diagnosis. Symptoms of chronic endometritis include the following:
- there is a significant loss of thickness of the uterine mucosa,
- sometimes, due to an inflammatory focus, a reverse reaction can occur; significant mucosal thickening,
- with ultrasound, the uterus can be enlarged,
- displacement of the uterus in any direction (anatomical change of location),
- the presence of multiple adhesions.
Although ultrasound is the original method and the most commonly used method for detecting pelvic disease, it should be considered only indicative. If any abnormalities or abnormalities have been found, additional research is necessarily ordered - hysteroscopy, which will allow you to fully see the uterus. After that, the doctor may prescribe to do a biopsy.
Types of Endometriosis
Genital endometriosis can be internal, affecting the body of the uterus, and external, in which the disease spreads to the ovaries, fallopian tubes, vagina, cervix, and peritoneum.
Internal endometriosis is of three degrees. The first of them affects the upper layers of the myometrium by 2-3 mm. In the next stage, the uterine wall is affected up to half of its thickness. The third degree of the disease is characterized by a complete defeat of the myometrium (up to the serous membrane). With endometriosis, ultrasound diagnostics will be informative only in the second and third stages of the disease..
Signs of the disease and its detection
One of the important questions that should be clarified before the procedure: when is it better to do an ultrasound? The most suitable are considered 23-25 days of the cycle. This is due to the peculiarities of physiological processes occurring in different phases of the menstrual cycle.
In phase I (1-11 days), a reduced echogenicity and homogeneity of the endometrium is noted, the line of closure of the anterior and posterior layers of the uterine mucosa is clearly visualized. This condition does not allow to diagnose endometriosis with high accuracy. During the period of ovulation (12-15 days), the endometrial echogenicity increases, but this process is uneven, therefore false signs of endometritis or other pathological conditions can be detected.
And only in the second, secretory phase of the cycle (16-28 days), the endometrial echogenicity becomes maximal, and the line of closure of the mucous membranes is erased. This creates the most suitable conditions for detecting various pathologies of the endometrial layer of the uterus, since during this period their severity becomes maximum.
If you are interested in which day of the cycle to undergo an ultrasound, then plan a study for the second half of the menstrual cycle.
Signs of endometriosis on ultrasound
On ultrasound for endometriosis, the following changes can be detected:
- increased echogenicity of myometrium,
- echogenic inclusions of up to 5 mm located in the thickness of the uterus walls (in some cases they merge with each other, forming cavities),
- an increase in the anteroposterior size of the uterus, due to which it acquires a rounded shape,
- uneven thickness of the uterine walls, endometrial hyperplasia,
- bend of the uterus (in 15% of patients),
- presence of signs of chronic endometritis on ultrasound,
- dilation of blood vessels (they look like they are affected by varicose veins),
- bladder deformity due to uterine pressure,
- the presence of various tumors (endometrial polyp, nodules, etc.).
The greater the number of symptoms listed in the patient during the study, the more accurate the diagnosis.
One of the most important manifestations of the disease is the presence of small endometrial nodes in the walls of the uterus. They can have both the correct, and irregular form.
There is no clearly demarcated border between them and the neighboring tissues. At the same time, the echogenicity of the node is significantly higher than that of the myometrium.
Cystic cavities may be present inside the endometrial node, which can be seen on ultrasound as inclusions with low echogenicity.
Changes in endometriosis in patients of different ages
In girls and women aged 12–20 years, an ultrasound shows a spherical shape of the uterus, but other signs of pathology may be absent. So, the uterus is not compacted and not enlarged (if only insignificantly). At reproductive age, you can see the signs listed in the previous section, and during menopause, the size of the uterus decreases, but its shape remains spherical.
In most cases, the doctor makes an assumption about the presence of endometriosis in the patient on the basis of the collected history and examination, but the final diagnosis can be made only after the implementation of ultrasound. Its results provide the specialist with grounds for setting a further examination (if necessary) or therapy aimed at eliminating the symptoms of the disease.