Can Endometriosis Be Seen on Ultrasound? | Pelvic Health Insights

Let’s discuss the often misunderstood issue of pelvic pain. If you’ve ever had an ultrasound and left feeling confused, or thought, “Can they actually see endometriosis on this thing?”-you’re not alone. Endometriosis affects about 10% of menstruating women around the world, but it is hard to detect on imaging[1]. However, that doesn't mean your symptoms are not real.

In this guide, we will explain how ultrasound helps with the diagnosis of endometriosis. You will learn about the signs that radiologists look for. We will also talk about what to do when things are still unclear.

What is Endometriosis?

Endometriosis can be a frustrating and painful condition, where tissue that looks like the endometrium (the lining inside the uterus) grows outside the uterus. This can happen on the ovaries, fallopian tubes, bladder, and bowel. This tissue reacts to hormonal changes. It bleeds during the menstrual cycle, but it cannot leave the body like the uterine lining can. This causes inflammation, scar tissue, and cysts. Many people experience chronic pelvic pain because of it[1].

Diagnosis can take a long time. Typically, it takes about 7 to 10 years for people to get the right diagnosis. This is often because imaging tests look normal or symptoms are placed on the wrong problem[4].

Can Endometriosis Be Seen on Ultrasound?

The answer: sometimes.

Transvaginal ultrasound (TVUS) is good at spotting signs of endometriosis, especially when the disease is moderate to severe. It works well for finding:

• Endometriomas: Ovarian cysts that hold old blood.
• Deep infiltrating endometriosis (DIE): Affects pelvic ligaments and organs like the bladder or bowel.
• Adhesions: When organs get stuck due to scar tissue.

Superficial endometriosis can cause a lot of pain, but it might not show up on imaging tests. A skilled operator is very important because the accuracy of TVUS relies heavily on their training and technique[3].

How is Endometriosis Diagnosed?

A full diagnostic workup often includes:

• Symptom assessment: Check menstrual history, GI or bladder symptoms, and pain levels.
• Pelvic exam: This may show tenderness or bumps.
• Transvaginal ultrasound (TVUS): This is the first tool for imaging.
• MRI: For more detailed images, especially when the bowel is involved.
• Laparoscopy: The gold standard for surgery. It uses small incisions to let doctors see and take samples of lesions[1].

What Does Endometriosis Look Like on Ultrasound?

On TVUS, trained radiologists look for:

• Endometriomas: Cysts on ovaries that look like "ground glass."
• Nodules or thickening found on the rectovaginal septum, bladder wall, or uterosacral ligaments[3].
• Lack of organ mobility, which may show adhesions.
• Bowel wall irregularities, indicating deep infiltration[2].

Superficial peritoneal lesions are mostly hard to see using ultrasound.

When to Get an Ultrasound for Endometriosis

An ultrasound may be helpful if you experience:

• Ongoing pelvic or menstrual pain
• Pain during sex or when using tampons
• Stomach issues that change with your cycle
• Swelling in the belly (“endo belly”)
• Trouble getting pregnant
• Pain during bowel movements or when urinating

Ultrasound can find changes in the structure of things and help plan what to do next. However, it is not enough by itself to give a clear answer.

Common Symptoms of Endometriosis You Shouldn’t Ignore

• Strong menstrual cramps that don’t get better with NSAIDs
• Pain during sex (dyspareunia)
• Discomfort in the lower back, pelvis, or hips
• Stomach issues like bloating, diarrhea, or constipation
• A strong need to urinate or a burning feeling (without an infection)
• Problems getting pregnant (infertility)
• Tiredness and trouble thinking clearly[1]

These symptoms might get worse during your period. However, they can also continue every day.

How Endometriosis Affects Pelvic Health Over Time

Chronic inflammation caused by endometriosis can result in:

• Pelvic floor dysfunction: Muscles can tighten when there is pain.
• Nerve irritation: This affects nerves like the pudendal and hypogastric nerves.
• Bladder and bowel dysfunction
• Sexual dysfunction: Often leads to avoiding intimacy.
• Mental health problems, such as anxiety and depression[5][4]

Untreated endo can lead to a cycle where pain gets worse and function decreases over time.

What If My Ultrasound is Normal but I Still Have Symptoms?

It happens more often than you might believe. A lot of people with endometriosis get normal ultrasounds. This is particularly true if the disease is in its early stages or not deep[1].

That doesn’t mean:

• Your pain is not real.
• You do not have endometriosis.
• You should not seek care.

Getting a second opinion or seeing a specialist for pelvic pain is usually a good idea.

Pelvic Floor Dysfunction and Endometriosis

When your body hurts, your pelvic floor muscles often tighten to protect you. This reaction is called guarding. It can cause:

• Pain during sex
• Trouble emptying your bladder or bowels
• Feeling of heaviness in the pelvic area
• A burning or aching feeling in the lower pelvis

Pelvic floor physical therapy can help to lessen this problem. It does this by using specific hands-on treatments, stretching, breathing methods, and re-training the nervous system[6][5].

Endometriosis and Fertility: What Ultrasound Can-and Can’t-Tell You

Ultrasound can detect:

• Endometriomas, which can lower ovarian reserve.
• Distorted anatomy caused by adhesions.
• Blocked or swollen fallopian tubes.

But it can’t evaluate:

• The quality of eggs
• Signals from hormones
• Early problems that affect implantation

About 30–50% of people with endometriosis have fertility problems. However, many are still able to get pregnant naturally or with the help of assisted reproductive technology[1].

Can You Detect Deep Infiltrating Endometriosis on Ultrasound?

Yes-with the right tools and expertise.

DIE affects tissues that are deeper than 5 mm. It usually impacts:

• Rectovaginal septum
• Uterosacral ligaments
• Bladder and bowel walls

TVUS can find DIE with over 90% sensitivity when done by specialists[2]. This makes it a strong method for diagnosing without surgery.

What Are the Limitations of Ultrasound for Endometriosis?

• Misses surface problems
• Relies on the skill of the operator
• Not very good for non-pelvic endometriosis (like in the diaphragm or lungs)
• Might miss adhesions unless they change the shape of organs

It is a helpful tool, but it should only be one part of a complete assessment[3].

Alternative Imaging Tools for Diagnosing Endometriosis

If the ultrasound does not provide clear results, your doctor might suggest:

• MRI: Gives a better look at soft tissue. It is great for checking the bowel and bladder.
• Sonovaginography: A special type of ultrasound that uses fluid for better pictures.
• Laparoscopy: This is still the best method for diagnosis and treatment.

A radiologist who knows about endometriosis should read MRI and advanced ultrasound images. This ensures better understanding and accuracy[3].

Treatment Options After an Endometriosis Diagnosis

• Hormonal treatments: Birth control pills and GnRH agonists
• Laparoscopic surgery: This takes out visible lesions
• Pelvic physical therapy: It helps with muscle and nerve pain
• Diet and lifestyle: Aiming for anti-inflammatory methods might be beneficial
• Fertility assistance: Options include IUI, IVF, or surgery if required

There isn't a single solution for everyone. A team approach to care works best[1].

Pelvic Therapy for Endometriosis: How It Helps

At Blossom, we think therapy should look at the entire pelvic system-not just the uterus.

Pelvic floor therapy can help:

• Train your active muscles again
• Reduce pain with sex
• Better control of your bladder and bowel
• Relax the nervous system
• Bring back trust in your body

Studies show that this method greatly lessens chronic pelvic pain. It also makes the quality of life better[6][5].

How to Prevent Pelvic Health Problems If You Have Endometriosis

You can't stop endometriosis itself, but you can avoid flare-ups and problems.

• Keep a record of symptoms and cycles.
• Push for a check-up early.
• Start pelvic therapy to remain active and functional.
• Lower inflammation with good nutrition, rest, and reducing stress.
• Assemble a caring support team.

Q&A: Everything You’re Wondering About Endometriosis and Ultrasound

Q: What is the best imaging test for endometriosis? A: The best way to diagnose is still through laparoscopy, a minimally invasive surgery that allows doctors visibility through small incisions. This method lets doctors see and remove problems directly. However, transvaginal ultrasound (TVUS) is a great first choice for imaging. When done by skilled professionals, it can find deep infiltrating endometriosis (DIE) and ovarian endometriomas very accurately[2][3].

Q: Can you see endometriosis on abdominal ultrasound? Abdominal ultrasound is not as effective as transvaginal ultrasound (TVUS). It can find large ovarian cysts, but it often misses smaller or deeper problems. On the other hand, transvaginal ultrasound is performed closer to the areas of interest. This leads to clearer images, especially when done by trained professionals[3].

Q: How accurate is ultrasound for endometriosis? A: A study found that TVUS can find deep infiltrating endometriosis with 91% sensitivity and 98% specificity if done by skilled professionals[2]. However, it often misses superficial peritoneal lesions. This shows how important clinical evaluation is.

Q: What does an endometrioma look like on ultrasound? An endometrioma is a type of cyst that often looks like a smooth “ground-glass” surface. You can usually find these on the ovaries. They are one of the easiest signs of endometriosis to spot when using ultrasound[3].

Q: Does a normal ultrasound mean I don’t have endometriosis? No, many people with superficial or early-stage endometriosis can have normal imaging results. Imaging often misses non-invasive lesions. Because of this, diagnosis mostly relies on the patient's symptom history and the doctor's judgment[1].

Q: I have bowel symptoms. Can ultrasound detect bowel endometriosis? Yes, trained specialists can use transvaginal ultrasound (TVUS) to find deep infiltrating endometriosis that affects the rectosigmoid colon. It works well when they use the right techniques, like bowel preparation or rectal water contrast. This method has been shown to effectively identify bowel involvement.

Q: What should I do if my doctor won’t refer me for an ultrasound? A: Stand up for yourself. Many women experience long waits and feel ignored while trying to get a diagnosis[4]. If you think your symptoms feel like endometriosis, ask for a referral to a gynecologist or a specialist in pelvic pain who understands this condition.

Q: Is it worth getting an ultrasound even if I’ve already been diagnosed with endo? Yes, ultrasound can help watch for changes in endometriomas. It can also find new growths and assist in planning for surgery or fertility treatments. It is a valuable tool for ongoing care[1].

Q: How long does a pelvic ultrasound take, and is it painful? A transvaginal ultrasound usually takes about 15–30 minutes. It may feel uncomfortable, especially if your pelvic floor is sensitive, but it shouldn't be very painful. If you feel any discomfort, telling your provider can help them change their approach.

Q: Can pelvic floor therapy still help if imaging shows nothing? Chronic pelvic pain is usually linked to pelvic floor problems. These issues cannot be seen on scans. Research shows that pelvic floor physical therapy can help reduce pain. It can also improve muscle control and quality of life, even if the scans look normal[6][5].