Endometriosis is an insidious disease is which notoriously difficult to diagnose without surgery. There are significant impacts of not reaching a diagnosis, and significant patient burden in the experience of this disease. Access the high quality imaging is essential in the care of patient with suspected and confirmed endometriosis to allow tailored treatment pathways.

This presentation will discuss various forms of endometriosis and the ultrasound assessment of endometriosis, including ovarian endometriomas, deep endometriosis, and emerging aspects of endometriosis diagnosis. It will also discuss pitfalls in the diagnosis of endometriosis.

Deep endometriosis is a complex and often underdiagnosed condition, and its detection on transvaginal ultrasound requires not only technical skill but also a keen eye for subtle sonographic clues. This presentation will focus on the nuanced and less obvious manifestations of deep endometriosis that sonographers may encounter in routine practice. Particular attention will be given to involvement of the uterosacral ligaments (USLs) and the rectouterine pouch (Pouch of Douglas), where disease may present with subtle findings that can be easily overlooked.
The concept of “soft signs” such as ovarian immobility will also be explored, highlighting how restriction of ovarian movement may indicate deep endometriosis of the pelvic sidewall or USL involvement, even in the absence of overt nodules. Attendees will gain practical insight into systematic scanning techniques, dynamic assessment, and the importance of correlating findings with clinical symptoms.
Through case examples and high-resolution video clips, this session aims to sharpen the sonographer’s ability to detect these elusive signs, enhancing diagnostic confidence and ultimately improving patient care.

The MUSA (Morphological Uterus Sonographic Assessment) criteria provide a standardised ultrasound framework for diagnosing adenomyosis to improve diagnostic accuracy and consistency in imaging reports. The exact pathophysiology of adenomyosis is not fully understood, however, it is commonly thought to result from the invasion of endometrial glands and stroma into the myometrium. It can cause dysmenorrhoea, pelvic pain, dyspareunia, heavy menstrual bleeding, and it may also affect women’s fertility. Accurate ultrasonic diagnosis enables appropriate treatment options to be offered to patients.

Detecting adenomyosis on ultrasound can be challenging, but using the right imaging techniques and looking for key features can significantly improve accuracy. Recognition of both direct and indirect sonographic features is the key to ultrasound diagnosis.

This presentation provides tips and tricks to aid the ultrasonic identification of MUSA features and diagnosis of adenomyosis in clinical practice.

The MUSA (Morphological Uterus Sonographic Assessment) criteria provide a standardised ultrasound framework for diagnosing adenomyosis to improve diagnostic accuracy and consistency in imaging reports. The exact pathophysiology of adenomyosis is not fully understood, however, it is commonly thought to result from the invasion of endometrial glands and stroma into the myometrium. It can cause dysmenorrhoea, pelvic pain, dyspareunia, heavy menstrual bleeding, and it may also affect women’s fertility. Accurate ultrasonic diagnosis enables appropriate treatment options to be offered to patients.
Detecting adenomyosis on ultrasound can be challenging, but using the right imaging techniques and looking for key features can significantly improve accuracy. There are tips and tricks that can help to optimise imaging; performing transvaginal sonography, using a mid-range frequency and gain, applying gentle transducer pressure, utilising harmonic imaging, and performing a slow sweep to assess myometrial echotexture.
Recognition of both direct and indirect sonographic features is the key to ultrasound diagnosis. The direct features indicate the presence of echogenic endometrial tissue within the myometrium, including an irregular and/or interrupted junctional zone with subendometrial lines and buds, hyperechogenic islands in the myometrium, myometrial cysts with an echogenic rim, and fan-shaped shadowing. On color/power Doppler imaging vessels typically cross an adenomyotic lesion (translesional vascularity), in contrast to the circumferential vascularisation seen around fibroids.
The indirect features include an increase in the uterine volume secondary to the presence of ectopic endometrial tissue within the myometrium, as well as globular appearance and/or asymmetry in myometrial wall thickness.