E2664. Endometriosis: How to Find What’s Hidden in Plain Sight
  1. Tucker Burr; University of California Los Angeles Health
  2. Jena Depetris; University of California Los Angeles Health
Endometriosis is prevalent, underdiagnosed, and can impose serious limitations on activities of daily living. Although not the gold standard for diagnosis, there are important advantages to imaging with both US and MRI. This exhibit is intended to provide guidance to the radiologist including technique and protocol for targeted endometriosis evaluation, correlating symptoms to findings, and recognizing subtle findings of disease.

Educational Goals / Teaching Points
One in ten women will experience endometriosis, subsequently enduring higher rates of chronic pain and infertility for up to 10 years before establishing a diagnosis. We will show the value of targeted endometriosis specific protocols for US an MRI to detect disease, which is important as there is not only a range of anatomic distribution, there is age distribution, and cyclical changes of menstruation also accounting for a wide range of presentations. Specific case examples will provide a window into the range of imaging presentations while highlighting the most common findings.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Endometriosis is best evaluated radiologically with dedicated transvaginal US and MRI protocols. On ultrasound examination, there are several key anatomic locations that need to be included to have the best chance at diagnosis including the uterus and adnexa, dedicated evaluation for deep infiltrating implants, assessment of sliding sign, and then subjective tenderness and mobility of other organs. On MRI evaluation, important sequences include T1 precontrast with fat saturation and T2 weighted images to assess for deep infiltrating disease. Recognizing the location and extent of disease is important for correlation of symptoms with the three main types of disease including ovarian, peritoneal, and deep infiltrating endometriosis. The most common location is the ovaries, often presenting with an adnexal endometrioma. Endometrial implants may be found superficially throughout the peritoneal lining of the abdomen. Deep infiltrating disease is defined as implants that penetrate >5 mm below the peritoneal lining. Certain imaging signs are important to identify as hallmarks of and extent of disease. Endometriosis may produce thickening of pelvic fascia and ligaments with attention to the uterosacral ligaments and vaginal wall. The mushroom cap sign of thickened muscularis propria often reflects deep infiltrating disease, although is not specific for the disease. Kissing ovaries describes adherent bilateral endometriomas. Assessing for the sliding sign on ultrasound is an important dynamic evaluation for inflammatory changes. The radiology team can have a real impact on patient care by increasing sensitivity with US and MRI evaluations as well as recognizing the wide manifestations of disease.

Endometriosis is an under-recognized disease that can greatly affect patient well-being. Familiarity with optimal evaluation techniques, pathophysiology, and a range of disease processes can lead to more accurate diagnosis and improved patient care.