Study finds correlation between TVS ‘soft markers’ and endometriosis

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Ovarian immobility on transvaginal ultrasound (TVS) is strongly linked to endometrioma, posterior compartment deep endometriosis (DE) and pouch of Douglas (POD) obliteration, according to a prospective observational study.

The Australian study in the European Journal of Obstetrics & Gynecology and Reproductive Biology also found ultrasound “soft markers” for isolated superficial endometriosis (SE) localized to the pelvic sidewall and uterosacral ligament (USL).

“Site-specific tenderness may also be a sign of isolated sidewall SE,” wrote the authors. 

The study sought to determine if symptoms and/or TVS-based “soft markers” are associated with endometriosis type and location in women with suspected endometriosis who were referred to tertiary care centers.

The multicenter study was conducted at nine tertiary care centers in Sydney, Australia, between January 2009 and February 2013.

In total, 220 consecutive women were recruited, of whom 189 participants with preoperative TVS ultimately underwent laparoscopy and comprised the final analysis.

Mean age of the women was 32.2 years and 48.7% had a history of endometriosis, whereas prevalence of endometriosis was 77.2%.

SE was present in 64.6% of the women. Isolated disease with no evidence of endometrioma/ DE was detected in 54.1% of this patient subset, and diarrhea was the only symptom notably linked to isolated SE.

On the other hand, endometriomas were observed in 24.3% of the entire cohort, with 8.5% having bilateral lesions. But 7.9% had only a right endometrioma and 7.9% had only a left endometrioma.

Presence of endometrioma at surgery strongly correlated to posterior compartment DE: 60.9% vs. 19.1% without endometrioma. More specifically, anterior rectal/rectosigmoid DE was much more prevalent among women with posterior compartment DE: 50.0% vs. 12.8% without.

In addition, posterior compartment DE was visualized in 30.2% of the study population and 24.9% of the entire group had POD obliteration, which was confirmed in 93.6% of women who underwent complete surgical dissection.

For women with unilateral and bilateral endometrioma(s), symptoms significantly associated with ovarian immobility on TVS included dyschezia, dysmenorrheal, rectal bleeding, right or left lower abdominal pain and tenesmus.

Unilateral ovarian fixation on TVS was identified in 36.0% of the entire study cohort, whereas 16.4% had bilateral ovarian immobility. 

“When participants with endometriomas, posterior compartment DE, and/or POD obliteration were excluded from the analysis, left ovarian immobility and left USL SE was the only significant  correlation” between ovarian immobility and surgical features, in the absence of endometrioma, wrote the authors.

Among women with ipsilateral pelvic sidewall SE, but minus endometrioma/POD obliteration/DE, accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for ovarian immobility with TVS for the left ovary were 71%, 16%, 87%, 27% and 78%, respectively.

For the right ovary, the results were 82%, 7.0%, 94%, 14% and 87%, respectively. 

Finally, for site-specific tenderness (SST), data from a verbal numeric rating scale (VNRS) from available patients revealed there was a statistically significant association between left adnexal SST and left pelvic sidewall SE in the absence of endometriomas/DE/POD obliteration. 

“This study helps to further characterize the relation between ovarian fixation and SST on TVS and specific endometriosis types and locations,” the authors wrote. 

Self-reported right and left lower quadrant pain significantly associated with ovarian immobility on the corresponding side, even without endometrioma, also suggests that the location of ovarian adherence to surrounding structures could impact the site of pelvic pain symptoms. 

Moreover, potential TVS “soft markers” may help develop a model to predict isolated SE preoperatively, thus improving surgical planning.