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Advanced Gynecology Ultrasounds For Endometriosis & Adenomyosis

Author Taylor Spurgeon-Hess covers Advanced Gynecology Ultrasounds For Endometriosis & Adenomyosis on BackTable OBGYN

Taylor Spurgeon-Hess • Apr 20, 2023 • 183 hits

Advanced gynecology ultrasounds allows for the collection of additional information when diagnosing and managing conditions such as endometriosis and adenomyosis. Creating an advanced gynecological ultrasound clinic can streamline the process and increase both patient and physician satisfaction. Despite the positive outcomes, some barriers exist which prevent the widespread implementation of these clinics.

Dr. Mathew Leonardi discusses his experience in creating and implementing an advanced gynecological ultrasound clinic. This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable OBGYN Brief

• Performing an ultrasound scan on each and every patient can help detect unsuspected or deep infiltrating diseases.

• Advanced ultrasound care can help detect conditions such as endometriosis and adenomyosis.

• An advanced gynecological ultrasound clinic allows for “all-in-one” visits for patients in which they receive a consult, a scan, and results within a single trip.

• The “all-in-one” approach increases efficiency and patient accessibility to care for patients in rural areas. It also decreases the hospital's labor costs by decreasing intake and secretarial work.

• For advanced ultrasound to become commonplace, Dr. Leonardi believes that gynecological surgeons need to become more hands-on with ultrasound scans and perform more of them themselves.

An advanced ultrasound showing cysts from endometriosis

Table of Contents

(1) Does Endometriosis Show Up On An Ultrasound?

(2) Setting Up a Gynecological Ultrasound Unit

(3) Changing the Culture of Gynecologic Ultrasound

Does Endometriosis Show Up On An Ultrasound?

Yes, advanced gynecology ultrasounds can detect conditions such as endometriosis and adenomyosis, as well as other causes of pelvic and abdominal pain. Previously, many physicians obtained ultrasounds only when searching for something specific or if their degree of clinical suspicion was high enough to warrant a scan. Today advanced ultrasound is increasingly commonplace in gynecologic care as its utility continues to be recognized. Specifically, ultrasound boasts a high sensitivity when diagnosing bowel endometriosis. Conducting a scan on everyone allows physicians to catch unexpected or deep infiltrating diseases.

[Dr. Mark Hoffman]
Let me ask you then, are you scanning 100% of your patients in whom you suspect endometriosis, so anybody with dysmenorrhea, pelvic pain? Then number two, which of those patients are you still ordering MRIs for anyone with the exception of abdominal disease? For anyone with pelvic disease, are you getting MRIs?

[Dr. Mathew Leonardi]
The answer to your first question is if I'm looking after somebody as their gynecologist, they will have a scan done by me or one of my direct team members with me overseeing that scan. I will literally never operate on somebody without doing that scan. From an endometriosis perspective, of course, there are ectopic pregnancies that come into the [unintelligible 00:54:00] I look at those pictures always, but I don't always scan those patients myself. Yes, I scan every single one of my patients.

The answer to your second question was how often do I use MRI? The answer is seldom. I will order MRIs in patients who describe upper abdominal symptoms, shoulder tip pain, catamenial pneumothorax type symptoms. I have an amazing radiologist, Dr. Basma Al-arnawoot, who is my go-to. She's the one that's starting to enhance the imaging domain of benign gynecology in our center, and she's really passionate about it. I order it for them.

If there's really terribly complex disease in a way that I can't be as comfortable with the mapping of it myself through ultrasound, maybe morbidly obese, lots of bowel content, where I'm like, is that a real bowel nodule or is it not? I'll often get Dr. Basma to do an MRI in those patients, so that way we have the two views.

[Dr. Mark Hoffman]
You've almost completely transitioned from MRI to ultrasound?

[Dr. Mathew Leonardi]
Yes. It's extremely rare. I would say maybe 1 in 100 patients will get an MRI.

[Dr. Mark Hoffman]
Are you bringing colorectal surgery in for patients that have colorectal disease? Is that something you learned to do-

[Dr. Mathew Leonardi]
Yes.



[Dr. Amy Park]
Is ultrasound better at diagnosing rectal disease endometriosis than MRI?

[Dr. Mathew Leonardi]
As per the literature, yes, it is with a very slight increased sensitivity, but they're both good. Again, operator-dependent and skill-dependent. If you have a really great radiologist looking at MRIs, they should really be able to tell you that there's bowel endo or not.

[Dr. Mark Hoffman]
I'm also not ordering MRIs on every patient for whom I suspect endo, but if I'm scanning everybody, then I'm going to be more likely to catch those patients that have the unsuspected or surprised deep infiltrating disease. Most of the time they have bowel symptoms, they have something [unintelligible 01:01:16] something that keys you into posterior cul-de-sac disease, but if I'm scanning them all myself, I feel like I can get that information right now as opposed to, "Do I get the MRI? It's going to delay surgery." That's really the motivation for me is to get that information in real-time, and it sounds like it's working for you.

[Dr. Mathew Leonardi]
Yes.

[Dr. Amy Park]
I find this very interesting because I remember the new hires here, Miguel Luna, did ground rounds on bowel endo and we talked about specifically ultrasound versus MRI. I couldn't remember all the details, but I really feel like we're at what you described as another inflection point. The imaging has gotten so much better for ultrasound diagnosing adenomyosis and endometriosis than when I was a resident. I finished my fellowship in 2009, so I finished residency in 2006.

Listen to the Full Podcast

Advanced Ultrasound for Endometriosis with Dr. Mathew Leonardi on the BackTable OBGYN Podcast)
Ep 7 Advanced Ultrasound for Endometriosis with Dr. Mathew Leonardi
00:00 / 01:04

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Setting Up a Gynecological Ultrasound Unit

Integrating advanced ultrasound care into a gynecological ultrasound unit allows for an “all-in-one” approach to a patient's concern; the patient can receive a consult, a scan, and a follow-up all in one visit which drastically increases the speed with which concerns are addressed. Additionally, for patients from rural areas, this setup allows for accessibility and elevates the patient experience. A sample setup could include two scan rooms, with ultrasound machines in each, and a few “talk” rooms. The patients would begin in a talk room, move to the scan room, and then redress and move to a talk room once again. This maximizes efficiency for the physician while also meeting patient needs. Proposing this plan to hospital administration can help gain approval for the purchase of expensive machines, sonographers, and clinic space as this business model saves money in the long run; it cuts out the work of intake and secretarial work for 2-3 separate visits.

[Dr. Mathew Leonardi]
There are definitely a few models that you can consider, but for me, one of the greatest benefits to being a sonologist is I can do a visit all-in-one with a patient. The traditional model of gynecologic care is you have a consult, talk with the doc and then they will write a requisition for you to go for an ultrasound. The patient leaves and at a later date, who knows how long thereafter they go for that ultrasound, and then there's a follow-up visit to discuss those findings. That could be a week or maybe it could be three months depending on your wait times. For me, all of that happens in one visit. My visits are long, they're probably about an hour because we talk to the patient, and then we do a scan and an exam, and then we talk to the patient. We have essentially three patient appointments in one patient appointment.

[Dr. Mark Hoffman]
Do you bring the ultrasound machine into the exam room with you or is there one room with the machine where they go into?

[Dr. Mathew Leonardi]
In my particular clinic, I have two machines dedicated to me and I have two what I call talk rooms. To try and improve the efficiency of the machine, we have a bit of a flow where people might start in a talk room, have a bit of a chat, empty their bladder, go in for their scan. Then once the scan is done, they're given privacy to address and get presentable again.

Sometimes these scans can be emotional for people or they can be even to degree uncomfortable, so we give them some time and then we bring them into another talk room. There's a bit of a flow. Keep in mind in my clinic I have fellows and I have residents and medical students, so some of the initial intake information is collected by them and then reviewed with me. The fellows are learning the advanced ultrasound as well. Sometimes they're performing the bulk of the ultrasound and then I come in over top, review their images in real-time in front of the patient and sometimes take a few more pictures if needed. Of course, over the duration of a fellow's training, which is two years, at the beginning there's a lot of extra pictures I'm taking. Then by the end, sometimes there's no pictures I'm taking because they're actually very competent and they've collected all the information they need. The structure of my clinic is very unique, everything happens in one timeframe for that patient. I think that's great for the patient overall because it's convenient. They're not visiting the hospital at multiple occasions, paying for parking, taking time off work. I realize that may not be the easiest model to have one-hour appointments. That's difficult.

[Dr. Mark Hoffman]
Amy and I have talked about this in the past too. In Kentucky, we have a big population of patients who are from rural areas coming to see us. We joke about it, like coming to Lexington, Kentucky is like going to Manhattan for a lot of folks. They're like one-way streets and parking garages, it's extremely overwhelming and it's very cost-prohibitive for them to come see us. Part of the fiber program I built, having the IR doc come to my clinic, having ultrasounds, MRIs, be able to be read the day of and seeing them all same day. That's the model that we used to build that. That was my thinking also for why I wanted a machine across the hall in my clinic, in my space so I could have them come to see me if we needed to do a scan and have slots open and we could be scanning the routine stuff too. Also have two to three slots per half day for all of my patients that come through so they can get a scan right then. They don't have to come back. Like you said, it can be weeks for the scan. I'm usually able to see them the day they get their scan so when they come back they just come right upstairs and see me that day to review the pictures in the scan. I've gotten it down to two visits now from three, but to have that machine and that availability in real-time has been a big push and I love hearing that that's how set it up. That's great. From a patient perspective, I'm sure they're just blown away that you're saving them weeks to months.

[Dr. Amy Park]
Yes, patient access and fit patient experience is huge here, what you're describing, both of you.

[Dr. Mathew Leonardi]
If there's an incentive from hospital administrators to focus on that patient experience and this is actually a really lovely model of care that can be considered. Now in Canada, we are in a fee-for-service model. The hospitals don't really make any extra money for the patients coming, so the hospitals are not so involved. In some ways a bit of a burden on us. I don't get to bill more though. There are some time-based things, but at the end of the day for me it's not about money.

Yes, of course, we all need to make money for our career. I feel like I'm really interested in pushing that agenda forward, doing the right thing, trying to encourage others to do that right thing for the patients, and not focus so much on the day-to-day billings. In time the money will come and I'll be fine, but I need to make sure that we're changing the game for these endo patients because the game is not working for them right now.

[Dr. Mark Hoffman]
I think Amy and I are on the same page, when we talk about money it's not because we're trying to figure out how to maximize our profit here. The thing though, especially in the US, the language we need to speak as physicians needs to include the financial side of it. If I expect my hospital to buy these machines, which are extremely expensive, and to purchase the time of sonographers and clinic space and all those things, we have to be able to justify that spend. We have to be able to justify the cost.

For me to have one patient visit that takes an hour but then opens up clinic space a week, two weeks, whenever they were supposed to come back, moving GYN and ultrasound out of the OB unit. Now I'm backfilling, so you have to look at total cost, and all those things. Why I think it's important is to be able to have that conversation in a meeting with your administrative side say, "Okay, this is what I want to do and here's why it's great for patients, it's great for turnover, and throughput and all those things."

It's also a smart business decision to condense all of that work into one visit. Then I can just go boom, to the OR we've just eliminated steps and obviously, the steps are bigger and tougher for our patients, but now I have to have two clinic appointments. I've to have an MRI room that patient twice and do intake twice and I have to have a frontdesk person do all of that work is doubled or tripled by having them come back. It is the kind of thing that a lot of us hear and we get pushback when we're asking about building new programs. I do think it's important to talk about those things as well because we have to be able to explain why it's important, not just for our patients, which is obviously is, but also how to get it done.

[Dr. Amy Park]
I agree. I think you have to make the argument from an administrative point of view. You have to spend money to make money and you need to examine, what Mark is describing is essentially decanting volume from the obstetric ultrasound unit to a gynecologic unit. I need $100,000 to pay for this machine or whatever you pay. Then if you can facilitate and fill your block time in an efficient manner here, I don't know about the Canadian system, but the more efficiently you can fill your ORs, that also is compelling. I know generally speaking, I'm assuming it's the same way in Canada, there's just not enough MIG surgeons to meet the demand. There's just too few of you, I would say PAG is the same way, Pediatric, Adolescent, and Gynecology. There's only 21 PAG graduates a year, and they're all spoken for MIG surgeons. You guys are like, I don't know how many fellowships there are 40 or 50 or something, but just not enough.

[Dr. Mathew Leonardi]
It really speaks to me to the prioritization of the obstetrics part of our specialty. Mark, it sounds like you have a very supportive Maternal Fetal Medicine Department head, I do as well. In general, our specialty is OBGYN and there's such a prioritization on pregnancy. You can't ignore pregnancy. It's visible and there is a volcanic eruption at the end. [laughter]

[Dr. Mark Hoffman]
It's coming no matter what we do, that train will arrive every day.

[Dr. Mathew Leonardi]
You can't ignore it. That is very different than the endometriosis patient who unfortunately is ignored a lot and is much easier to ignore because it's pain and it's women's pain. It's historical, it's societal, and so I think that's a big part of why there's a backlog of surgeries. There's not enough surgeons, there's not enough operative time. I certainly could use more operative time. I'm sure both of you could for your populations as well. These are bigger concepts that are not easy to fix. I know there's individuals across both of our countries that are advocates working for this. That's optimistic.

[Dr. Mark Hoffman]
Yes, and that's why I wanted to have you on. As we're doing all these things, as we're experiencing all of these challenges, is to have a roadmap from someone who's done it and say, "Okay, so I have access to a machine, I have clinic space, I have a stenographer. How do I learn how to do this?" I was lucky. I know my intern year, we did tons of hands-on scans, and then something happened where MedLegal was like, "Hey, you can't let an intern run around with an ultrasound machine in the ER. Who's looking at these scans?" There was no way to save the images. There was no way to prove that they had done it, so they stopped allowing us to use ultrasound point-of-care all the time. I had gotten 100 of scans my intern year. Then by the time I was a chief, they started bringing it back because they could allow those scans to be captured. I had one of my third years, "Hey, go scan this patient real quick, see if she's got an ectopic or what you think." She's like, "What do you mean go scan the patient?" I was like, "No, grab the probe, take a look and see if you think there's anything going on [unintelligible 00:41:15] She was an amazing resident, she's a GY oncologist now, looked at me and goes crazy.

Just having had those few hundred scans my intern year and using it as a point-of-care tool, I never forgot how valuable and powerful that was. I've continued to do that. I've continued to look at the scans I've had. I've called radiologists after the fact and say, "Hey, by the way, that was different than what you said," in a friendly way." They can learn too, but how do you learn to get better? How do you real-time learn to get better?

[Dr. Mathew Leonardi]
What I did when I first came back to my institution to McMaster was talk to the residency program director, and suggested that the ultrasound rotation should diversify from primarily obstetrics to gynecology as well. Even though in the guidelines for residency in Canada, there are very few line items that are gynecology focused that I think is going to change with time and I'm going to try to be behind that advocacy.

Now, I have usually a resident, third-year, fourth-year resident coming to the clinic. They come every week for about a four-week rotation. Certainly, it's not enough time to learn advanced things, but they definitely, by the end, know how to identify the uterus and find the ovaries, and they are picking up hands-on skill. Are they ready to go off into the world? No, not yet, but it's a first step. There are usually ultrasound rotations at a lot of institutions in residency programs. That's a way to start that learning. If they don't exist, build it in, find a way to build in an ultrasound rotation, or create an ultrasound elective for those that are interested in it. I think that's one tangible way that we can start that learning.

For me, the exposure to ultrasound was that pivotal moment of fascination. Getting to have my hand on the probe even though it was very much obstetrical focused in my PGY-1 year. I just loved the tool. Getting people to get familiar with it, the knobology of the machine, interacting with the patient. It's not hard to see that passion develop because it is so fun. I think that's one thing that I've done and it's been successful so far at inspiring people to think about it a little bit differently than they have. Fellowship programs as well is another way to start to integrate that into their training. In my training program here, they do become competent by the end. In other programs around the country, they're not getting that hands-on learning. Because this reputation for gyne ultrasound is growing here, I've noticed some of the programs are offering their fellows a day with the radiologist. They're starting that dialogue, and I think that's a place to start.

If that's where ultrasound is done, get the fellow to go and spend time with the radiologist, even if it's to learn MRI, just get that familiarity with looking at imaging. This is going to be a career project for me, changing the culture of GYN surgery to make future surgeon sonologist. The dialogue starts now. The slow culture change starts now.

Changing the Culture of Gynecologic Ultrasound

In order to increase the utilization of advanced ultrasound care in gynecology, the culture must change on both a micro and macro level. To create culture change on a micro level, Dr. Leonardi believes that gynecologists should pick up the probe and personally perform the ultrasound scans. This provides the surgeon with a dynamic image of their patient’s condition and can increase the quality of care as residual disease is less likely to be left behind. On a larger scale, physicians can promote change by emphasizing continued learning and the value in asking for help. Currently, the increased focus on quality and safety can improve patient outcomes in the short term, but this practice leaves less room for inquiry and introspection: two key elements of a system capable of adopting new technology and practices.

[Dr. Amy Park]
I think that you bring up such a good point, Matthew, because I remember watching my mentor, one of my mentors, Mark Walters, give, I think it was the Ray Lee lecture at the American Urogynecologic Society. One of the points that he made-- because he did a lot of courses, training international folks on surgery. His main observation about teaching these physicians was that the people who got better were the ones who wanted to get better and engaged in self-inquiry and really tried to gain insights from their successes and failures.

That takes introspection. I don't think medicine really lends itself to introspection and judgment and that self-inquiry as much as-- it's not really ingrained as much in our culture. I think now it's getting more with this quality and safety, but sometimes that can feel punitive I think. I think that that's something that we always should be trying to impart to our trainees, that sense of humility. I think no surgeon is immune from complications. We can always do better, but you can't be complacent.

I think these are lessons that you learn, and I think you bring up a great point. Athletes are never satisfied with their performance. I love the analogy of the athletes. I think you're right, trying to learn. That's what I saw in Mark the whole time. You see the greats really always trying to get feedback and learn. I really appreciate that point that you made because it's never going to be easy. I think we should always try and embrace the challenges. I think that just because you do a fellowship doesn't mean you're like stop learning or what have you. Not that people think that.

[Dr. Mark Hoffman]
It's also a culture change. Amy, that's such a good point you bring up, but it's a culture change. When I first started where I was and I was the only person doing what I do, you'd ask for help and you get the feeling like, "Do they think I'm a bad surgeon for asking for help?" There's this idea that, like you said in medicine, that humility can be confused with weakness, or all of it is to get better. That's the only goal. That's all there is. I know I talked about my brother earlier.

I was complaining one day about having a hard day in residency and maybe screwing up something. He said, "Was the attending right?" My brother's not in medicine. I was like, "What do you mean?" "This is about me and my hard day and feeling bad about myself." He's like, "No, no, it's about whether they were right. If they were right, you learn and get better. If they weren't then you were right, then don't worry about it." It was a very simple just get better every day. Forget the rest of it, all the other stuff.

Amy, that's such a great point you bring up. Learning is something in getting better we have to do all the time, and that's why I really wanted to have you on because I want to learn, I want to get better. I want to incorporate a lot of what you're doing into my practice because I believe my patients need this, they need me to get better.

[Dr. Amy Park]
Agreed. I think it's like a patient-centered goal here, what you're really describing, Matthew. I'll just say that here at the clinic, everyone is ordering MRIs because you really have to have the skillset. I admire the fact that you express this interest, but you're right. In North America, the ultrasound expertise is really centered on an MFM and family planning, I would say. They're very good at ultrasound and REI. For gynecologic surgery, I would not say that that's necessarily our strength. You're probably one of the few experts in North America really.

[Dr. Mathew Leonardi]
It's interesting that you both bring up the utilization of MRI. There's a lot of culture that's ingrained here. How radiologists do MRIs is certainly one of them, preferentially that is, to doing ultrasound or doing advanced ultrasound. You both know that radiologists for the most part, of course, there's generalization here, they don't scan people themselves. They don't get to meet the people themselves. They don't actually understand like we do as gynecologists who are working with endometriosis patients the plight of that endometriosis patient, how hard it is, how valuable that diagnosis is to them beyond the preparation for surgery. I talk about this concept of diagnosis is therapy and this has nothing to do with planning for surgery. This has everything to do with the patient deserves to know and the features around that.

[Dr. Mark Hoffman]
It's powerful.

[Dr. Mathew Leonardi]
Yes, it is. We really do need a culture change. I think that's the biggest obstacle, and that's obviously a massive obstacle. How to create that culture change around the integration of ultrasound into our specialty. The other day I made a comment on Twitter, maybe controversial. I said the only way that I see us advancing in this particular field is if the gynecologist starts to hold the probe themselves.

I do not think that we're going to see as much uptake in the world of radiology as we can see if we become the individual behind the probe with the machine. Truthfully, instead of doing an examination to try and feel for a uterosacral ligament nodule. For the listeners here, you can't see. I'm doing air quotes right now. The ability of our physical exam is so minuscule compared to the ability of the ultrasound probe, which allows you to get some dynamic feedback from the patient in terms of where they're experiencing tenderness with respect to disease sites or adhesions, but you see it with your eyes.

When you see it with your eyes, you believe it and the patient believes it, and then it carries forward to that absolutely essential preparation for surgery. This is something we can get into. There's obviously a few concepts here that we can get into. I'm a firm believer that even the most advanced gynecologic surgeons, if they're not integrating advanced imaging beforehand or don't have an interpreter of that advanced imaging, they're probably unintentionally and unknown to them, leaving disease behind.

I use ultrasound in the operating room to guide the dissection. Sometimes I use it to immediately preoperatively, as soon as the patient is asleep in their syrups, I do a quick scan to re-review, particularly the posterior compartment in those patients who have advanced disease, a lot of adhesions, because as you look into the pelvis laparoscopically and you see the bowel is stuck to the back of the uterus, sometimes the ovaries are not even visible at the beginning of the procedure, and you start to dissect those spaces, you open your retroperitoneum, you do your ureterolysis, you start to do enterolysis, your bowel comes off the back of the uterus, it looks messy. It looks difficult to actually interpret what's what, is this just the dissection plane, or is there a nodule here?

If you don't already know that information preoperatively and believe that information preoperatively, we're probably actually leaving disease behind that we just don't know is there because it looks all messy. It doesn't look like the classic superficial endometriosis deposit blue-black or flame-like. I think it's really necessary for us to actually start to do the scan ourselves so we can visualize the disease three-dimensionally, sonographically, and then compare that to the surgical view, which allows us to guide our surgical approach.

Podcast Contributors

Dr. Mathew Leonardi discusses Advanced Ultrasound for Endometriosis on the BackTable 7 Podcast

Dr. Mathew Leonardi

Dr. Leonardi is a minimally invasive gynecologic surgeon and sonologist with McMaster University Medical Centre in Hamilton, Canada.

Dr. Amy Park discusses Advanced Ultrasound for Endometriosis on the BackTable 7 Podcast

Dr. Amy Park

Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.

Dr. Mark Hoffman discusses Advanced Ultrasound for Endometriosis on the BackTable 7 Podcast

Dr. Mark Hoffman

Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.

Cite This Podcast

BackTable, LLC (Producer). (2022, December 1). Ep. 7 – Advanced Ultrasound for Endometriosis [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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