Which tests can I find helpful?
Diagnosing Endometriosis often requires a physical examination (feeling your tummy and a internal pelvic examination), assessments, and referrals. The diagnosis itself can be challenging at times because there isn’t, at present, a straightforward non-invasive diagnostic test.
There are however several tests which can be helpful for doctors to look for physical signs of Endometriosis and to also rule out other potential causes for your pain.
These tests may not be suitable for everyone, it’s important you speak with your doctor about these tests and any potential risks and complications.
It's important to know
It is important to understand that Endometriosis does not always show up on scans, therefore should your test results return inconclusive or clear, we would still encourage you to seek further medical help or tests if your symptoms are persistent and you still suspect Endometriosis.
Ultrasounds are very good at identifying ovarian endometriomas particularly, so if these are found then it is very likely that you do have Endometriosis.
They can also sometimes detect scarring and evidence of deeper Endometriosis, although this is less conclusive. Superficial peritoneal Endometriosis is very difficult to identify on an ultrasound and Endometriosis should certainly not be ruled out with a ‘normal’ scan.
Understanding this helps you and your doctor move on to the next best steps and investigation should not stop at this stage if your symptoms are still significant.
Which tests will I find helpful?
Below we have listed several tests you may find helpful through your Endometriosis journey. For some people, these tests can cause feelings of anxiety, especially if it’s your first time having them.
We call this ‘scanxiety’, and while its perfectly normal to feel nervous, knowing what to expect can help reduce these feelings.
Things you can do to help.
If you would feel more comfortable with a female doctor or sonographer carrying out these tests, be sure to mention this upon booking your appointment.
Just remember the expertise of this team is the most important aspect, and a female clinician with the correct expertise may not always be available and all clinicians are professionals who do it all day every day.
Some of these tests may be uncomfortable, therefore taking somebody along with you for support and scheduling these exams when you can take a day off school or work may be helpful.
Do not cancel your appointment if you are having your menstrual period, as sometimes this can make it easier to make a diagnosis. If of course you feel uncomfortable having a scan at this time, then it can be re-arranged. The doctor or sonographer will be used to scanning under all circumstances and it is entirely safe to do during your period.
Your doctor may perform a physical exam to manually feel for any abnormalities in your pelvis.
What to expect
You will be asked to undress from the waist down and either change into a gown or use a sheet to cover yourself. Your doctor will then ask you to lay on your back, sometimes you will be asked to bring your feet together and relax your knees apart (frog-legged position) or sometime asked to shuffle your bottom to the end of the examination table where your feet may be placed in stirrups, allowing your legs to relax and fall open either side.
There will usually be a nurse or other chaperone present to help you and the doctor and one should always be offered if they are not there already.
During this examination, using one hand your doctor will place two fingers inside your vagina and using the other hand, the doctor will gently press down on your lower abdomen. They are trying to feel for any nodules of endometriosis, the movement of the womb and ovaries, and any other findings such as cysts, fibroids, or other pathology.
Although it is not always easy, it is important to try and relax as much as you can during an internal examination. This can make it less uncomfortable and allow the doctor to assess things as well as possible. Although examinations like this can be uncomfortable they should not be painful, if this is the case then your doctor will stop right away – the finding of pain in certain areas can be useful to determine where endo might be, but it is never the intention to cause discomfort. You can ask for the examination to stop at any point.
An ultrasound scan is an imaging technique which uses sound waves to create a clear view of the inside of your body. This test is often used to check for any physical changes or abnormalities in your pelvis and identify cysts on your ovaries.
What to expect
Jelly will be placed onto your abdomen where your doctor will use a handheld device, gently rolling it across your abdomen and pelvis to capture images from inside. A scan through the tummy can often identify the womb and ovaries, but it is less able to see the areas where endometriosis is often found behind the womb and cervix. It can also be difficult to identify the ovaries if they are small or are in an unusual place. The best results for endometriosis are found by doing an internal, or ‘transvaginal’ scan.
A Transvaginal Scan
A transvaginal scan is still an ultrasound scan but rather than looking from the outside of your tummy it is able to look from the inside by using a probe that goes into the vagina. This gives clearer pictures of your pelvis than an external scan, particularly in the areas where endometriosis is most likely to be. The ultrasound probe is very slim and the scan is not usually uncomfortable. As with the internal examination, any areas of tenderness can be useful to find, although this is not the intention and if you find anything painful the examination can be stopped right away.
What to expect
You will usually be asked to empty your bladder, undress from the waist down and position yourself on the exam table, shuffling your bottom to the end of the bed so your feet can be placed in stirrups, allowing your legs to fall open either side. During this examination, your doctor or sonographer will gently place a thin probe inside the vagina (around 2-3 inches) allowing a clear assessment of your pelvis.
Your doctor will gently press down on your lower abdomen at certain points to ensure specific areas can be seen as clear as possible and to see how well the organs move around each other.
Magnetic resonance imaging (MRI)
MRI is used to scan almost every part of your body. This type of scan uses strong magnetic fields and radio waves to produce detailed images of the inside of the body. Depending on the size of the area being scanned, and the number of images taken, this test can last anywhere between 15 and 90 minutes and you will be awake.
You might be offered an MRI for your specialist team to look and see if there are any visible Endometriosis. This is most often done when there is a possibility of deep endometriosis or significant scarring. This is to best plan the next steps, particularly if an operation is being considered.
What to expect
The MRI scanner is a tube which is open both ends, which looks like a large doughnut. Depending on which body parts are being investigated, some may require you to lie headfirst and others, feet first, and a camera will be placed over you.
You may be required not to eat or drink anything usually for up to a few hours prior to your appointment, or you may be asked to carry out a type of bowel preparation, this is to allow you time to prepare for the scan.
As this scan produces strong magnetic fields, it is important to remove any metal objects before entering the scanning room such as jewellery; hearing aids; and anything else containing metal. You will be asked if you have any metal implants in the body from previous operations, accidents, or dental surgery. In most cases the MRI is still safe, but occasionally it can create problems. If you have had any dental implants or fixed retainers it is useful to ask your dentist if they are MRI safe and what type of metal they are made from. You may be asked to change into a gown, or the radiologist may allow you to wear your own clothes.
The scanning rooms are usually chilly. Wearing clothing garments which do not have metal zips, fastenings or underwires that will keep you warm is recommended. Your personal belongings will be placed in a small locker.
Some MRI scans involve a contrast or dye; this may be given in liquid form or by injection through a drip. This allows for certain tissues and body parts to show up and helps the radiologist identify areas of endometriosis and how they relate to other structures.
The dye can sometimes cause mild side effects, such as a warm feeling; feeling like you’re passing urine, dizziness; nauseas; a headache or skin rash. These effects are usually mild, and they shouldn’t last long.
Currently, a laparoscopy remains the only way to definitively confirm Endometriosis. This is because it provides opportunity for a reliable and thorough assessment inside your abdomen and pelvis. The best way to confirm endometriosis is by visual identification of Endometriosis and confirmation with a biopsy looked at under the microscope. However, it’s important to know that in some cases, Endometriosis may not be seen during this procedure, or there might be instances where tiny, microscopic patches of Endometriosis could be missed as these changes can be very subtle.
It is important that endometriosis is looked for in all areas by an experienced surgeon and if there is any suspicion, a biopsy should be taken, and all areas of concern treated.
Rest assured, the medical community is continually progressing in its advancements, understanding and diagnostic capabilities, striving to improve accuracy, and offer the most effective care possible.
What to expect
This procedure is performed under general anaesthetic. Initially, CO2 gas is used to fill the abdomen, allowing for surgeons to see inside for signs of Endometriosis using the laparoscope (a thin telescope camera). The laparoscope is normally passed through a small incision (5-10mm) inside or around the belly button and additional operating ports placed through small incisions (5mm) usually between your tummy button and hip bone on either side, or occasionally in the middle above your pubic bone.
Sometimes extra incisions are needed, but rarely more than three. If Endometriosis is seen, depending on where it is, your gynaecologist may combine your diagnostic laparoscopy with treating the Endometriosis.
Laparoscopy as a purely diagnostic procedure is not recommended and you should expect any surgery to be both diagnostic (identify and confirm endometriosis), but also therapeutic (treat any endometriosis found). There are cases when this may not be appropriate, for example if the degree of endometriosis identified was more than was expected or it is in a complex area.
In these cases, biopsies should be taken and a plan made for surgery at a later date, likely in a different hospital with the expertise to treat deep endometriosis, after discussion about all the risks and benefits. These are called tertiary units or ‘Endometriosis Centres’, which are regulated and accredited by a national body (British Society of Gynaecological Endoscopy, BSGE).
This ‘see and treat’ approach allows your gynaecologist to not only identify areas affected by Endometriosis, but to also to remove it, by either cutting it away or using heat to destroy it.
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