Endometriosis: the normal scan that proves nothing

Clinical Rounds, the GPAtlas podcast. Women's Health. 20 minutes. Published 6 November 2026. Free to listen.

From our Ocean topic Endometriosis, reviewed August 2026.

Transcript

Sarah: Hello, and welcome to GPAtlas Clinical Rounds. I'm Sarah, and this is the podcast where we take one thing you'll genuinely see this week and work out what to do with it.

Ben: And I'm Ben. Today it's endometriosis, which is in the news this week because of new tablets. But the sharp bit is much older than any tablet. It's the normal scan that sends people home for years.

Sarah: Hannah's twenty-six. She's a primary school teacher, and she's on my Tuesday list for the third time this year about her periods. She's missing a day or two of work every month. Sex hurts, deep down. She had a pelvic ultrasound last year and it was normal. And she says, quite flatly, 'I just want someone to tell me I'm not making it up.' Honestly, the easy move is to repeat the painkillers, remind her the scan was fine, and see her in six months.

Ben: Three things today. Why a normal scan and a normal examination don't rule it out. Why you start treatment now, alongside the scan and the referral, not after them. And why CA one two five is the wrong test for this question.

Sarah: Before Hannah, the news, because she'd read it. She came in with a headline on her phone about new tablets for endometriosis and fibroids. And her very first question was whether she could have them.

Ben: So here's what the news line actually says. Tablets NICE has recommended for endometriosis and fibroids, and prescriptions for them are going up fast. The report links that to patients being able to work more effectively. What it doesn't settle is who they suit, or how they compare with what you'd already offer. Rising prescriptions measure uptake. That's not the same thing as a trial.

Sarah: And it doesn't change the first job. Hannah hasn't got a diagnosis. Not even a working one. Three visits this year, and nobody has said the word endometriosis to her once.

Ben: New tablets are being prescribed more. That doesn't tell you who should have them. Name the condition first.

Sarah: So what should have made one of us say the word sooner? Remind me what we're actually dealing with.

Ben: Endometrial-like tissue growing outside the uterus. Usually on the pelvic peritoneum, the ovaries and the uterosacral ligaments. Deposits on the ovary form endometriomas, the chocolate cyst. It's chronic, inflammatory and oestrogen-dependent. And it's common. Roughly one in ten women and people assigned female at birth of reproductive age. Around one point five million people in the UK.

Sarah: One in ten. So in most surgeries I've probably got one in front of me, and I'm calling it period pain. What's the list that should make me stop and think?

Ben: Any one of these is enough. Pelvic pain for six months or longer. Period pain that's affecting daily life. Deep pain during or after sex. Cyclical bowel symptoms, especially painful bowel movements. Cyclical urinary symptoms, especially blood in the urine or pain passing it. Infertility alongside any of those. It includes young people aged seventeen and under. And the pain can start cyclical and become constant.

Sarah: One feature is enough to suspect it. Teenagers included. Pain all month doesn't rule it out.

Ben: Hannah had two of those before she'd even sat down. Period pain stopping work, and deep pain with sex. So once you're thinking of it, what do you ask?

Sarah: I went through it properly this time. How long has it been going on, and is it stopping work. Deep pain with sex. Bowel or bladder symptoms that follow her cycle. Heavy or irregular periods. Fatigue, mood, sleep. And then, for the first time in three visits, I asked about her family.

Ben: Good, because a first-degree family history, so mother or sister, makes it more likely. Heavy periods should make you think of coexisting adenomyosis. The question that changes treatment is whether she's trying to conceive. And suggest a pain and symptom diary over two to three cycles. It captures cyclicity and severity, and it gives you something concrete to look at together at review.

Sarah: Her mum had a hysterectomy in her forties for what the family just called bad periods. Nobody had ever connected the two. And no, Hannah's not trying to conceive. Not for a couple of years, she said.

Ben: Ask about mother and sister. Ask if she's trying to conceive. Start a symptom diary.

Sarah: Can I come back to what Hannah said at the start? That she wanted someone to tell her she wasn't making it up. That line's stayed with me all week.

Ben: Because the defining problem here is delay. The average wait from first symptom to diagnosis is often cited at around eight years. So in practice, think of it early, believe the symptoms, and start managing them rather than waiting for a definitive test. A suspected diagnosis is a valid diagnosis. And ask her directly about worries over fertility, and about not being believed.

Sarah: So I said it. I think this is probably endometriosis. Tissue like the womb lining growing outside the womb, bleeding with each period, causing inflammation and pain. There's no cure, but there are treatments that work, and we can start today, before every test is back. She cried, actually. Relief, mostly. Then she asked why nobody had said it at eighteen.

Ben: Eight years is the average wait. A working diagnosis is a real one, so say it out loud.

Sarah: Then I examined her. And honestly, I used to skip the internal examination for period pain. It felt like overkill for something I'd already decided was nothing.

Ben: Offer it. You're feeling for reduced organ mobility, a fixed or retroverted uterus, and tender nodularity in the posterior fornix over the uterosacral ligaments. Speculum, to look for visible lesions in the vagina and to assess the cervix. A palpable adnexal mass may be an endometrioma. And if she declines a pelvic examination, still examine the abdomen for masses.

Sarah: Hers was tender posteriorly, nothing else. But I'd always had irritable bowel syndrome, IBS, in the back of my mind for her, because she bloats. I'd half written it in the notes last spring.

Ben: IBS gives bloating and bowel change tied to defaecation, and it isn't confined to periods. Pelvic inflammatory disease brings abnormal discharge, cervical motion tenderness and infection risk factors. Adenomyosis is a bulky, tender uterus with heavy painful periods, often older or parous. Urgency and frequency with sterile urine points to bladder pain syndrome. And IBS and adenomyosis often coexist with endometriosis. So finding one doesn't close the case.

Sarah: Offer the pelvic examination. And IBS often sits alongside endometriosis, not instead of it.

Ben: Before the scan, the things that can't wait. Acute, severe pelvic pain, especially with shock or collapse. You're thinking ovarian torsion, cyst rupture or ectopic pregnancy. That's same-day assessment, and a pregnancy test before anything else.

Sarah: And the slow one that scares me is ovarian cancer. Because that's bloating and pelvic pain too, and I'd literally just written down that Hannah bloats.

Ben: Persistent distension, early satiety, pelvic pain, urinary urgency or frequency. Examine, then test. Forty or over, measure CA one two five, and arrange an urgent direct access ultrasound of abdomen and pelvis if it's at or above the threshold for her age. Thirty- nine or under, consider the urgent ultrasound, and don't use CA one two five alone to decide. Ascites, or a mass that isn't clearly fibroids, is an urgent suspected cancer referral.

Sarah: And postcoital or intermenstrual bleeding means look at the cervix and make sure the smear's up to date. Hannah's was. Fever, purulent discharge and cervical motion tenderness, I treat as pelvic inflammatory disease and arrange testing for sexually transmitted infections.

Ben: Sudden severe pain gets a pregnancy test and same-day assessment. Persistent bloating gets the age-based ovarian cancer steps.

Sarah: Now, Hannah's normal scan from last year. That's what I'd been leaning on, if I'm honest. Every time she came back, I'd glance at that report and feel reassured.

Ben: It's the commonest pitfall. Treating a normal examination or a normal transvaginal ultrasound as ruling it out. Superficial peritoneal disease is often invisible to both. Even a normal magnetic resonance scan, an MRI, or a laparoscopy done inexpertly, can miss it. NICE is explicit here: don't exclude endometriosis on a normal scan, and recognise that referral may still be needed.

Sarah: Hers was transabdominal, as it happens. So do I scan her again, or am I just repeating a test that's already told me nothing?

Ben: Scan her. Offer a transvaginal ultrasound to everyone with suspected endometriosis, even with a normal examination. General practice organises it. It finds endometriomas and deep disease in bowel, bladder or ureter, and rules out other pathology. Transabdominal is for when transvaginal is declined or not suitable. And it runs alongside treatment, not ahead of it.

Sarah: A normal scan doesn't exclude it. Offer a transvaginal ultrasound, and believe the symptoms over the images.

Sarah: Confession. I've sent a CA one two five for period pain before. Just to be safe. It felt like the responsible thing to do.

Ben: Most of us have. But the harm runs both ways. A normal result falsely reassures. And endometriomas and inflammation often raise CA one two five a little, which brings cancer anxiety and urgent referrals nobody needed. So don't use it to diagnose endometriosis. Let the clinical picture and the ultrasound guide you. Possible ovarian cancer is different: there you follow the age-based steps.

Sarah: Hannah had also read about a saliva test. She wanted to know if she could just do that instead of the scan.

Ben: NICE's draft healthtech guidance supported two tests in primary care while more evidence is collected. A saliva microRNA test, and abdominal sensor pads measuring gut electrical activity. Only where it's still suspected despite a normal examination and negative, inconclusive or unavailable imaging. Neither diagnoses it on its own. A third test wasn't supported. And it was draft, with final publication expected in October.

Sarah: Don't send CA one two five for endometriosis. The new tests are narrow, and neither diagnoses it alone.

Sarah: So, what I actually did for Hannah on the day. A three-month trial of analgesia plus hormonal treatment, because she's not trying to conceive. Transvaginal scan requested that afternoon. Review booked. A year ago I'd have waited for the scan, then waited for gynaecology, and only then thought about treatment.

Ben: And that's exactly what's changed. Treatment, the GP-organised ultrasound and referral can all happen at the same time, not one after another. You don't need a laparoscopy before treating. It's no longer a routine prerequisite. Review at three months for response and tolerability. Refer to gynaecology if treatment fails, isn't tolerated or is contraindicated, or symptoms persist or keep affecting daily life.

Sarah: She asked about the tablets in the news again. And about supplements, because a friend swears by them. And whether she should just push through it.

Ben: The tablets are a conversation inside that plan, not a way round it. Supplements, traditional Chinese medicine and Chinese herbal medicines aren't supported by the evidence. For flares, a symptom diary, local heat, paced activity and stress reduction help some people. For persistent pain, pelvic-floor physiotherapy, psychological support or cognitive behavioural therapy, and a structured pain programme. And signpost a national charity for peer support.

Sarah: Treat, scan and refer at the same time. Review at three months. Skip the supplements.

Ben: Flip it, though. Say Hannah had sat down and told you they'd been trying for a baby for a year.

Sarah: Then I don't start hormones. That much I do know. But I'm less sure what happens after the referral, and patients always ask me.

Ben: If fertility is the priority, prioritise referral to fertility or gynaecology services and don't start hormonal treatment. The pathway is expectant management for up to two years, including time already spent trying, or surgery. Then up to four cycles of intrauterine insemination with ovarian stimulation, or IVF. Surgery is specialist: excision or ablation of deposits, which can improve pain and fertility.

Sarah: So the year she's already spent trying counts towards the two. I'd write that in the notes on day one, because otherwise nobody adds it up and she starts the clock again.

Sarah: Trying to conceive means no hormones and early referral. Document how long she's been trying.

Ben: Right, exam corner. A twenty-nine-year-old has had painful periods and deep pain during sex for a year. Her pelvic examination and transvaginal ultrasound are both normal. She isn't trying to conceive. What's the most appropriate next step? A, reassure her that endometriosis has been excluded. B, request a serum CA one two five. C, start analgesia plus hormonal treatment for three months and review. D, refer for diagnostic laparoscopy before starting any treatment.

Ben: C. A normal examination and a normal ultrasound don't exclude endometriosis, so you treat on a working diagnosis, review at three months, and refer if it isn't settling. D is the tempting one, because laparoscopy feels definitive. But it's no longer a routine prerequisite before treatment, and waiting for it is exactly the delay you're trying to avoid. And B is wrong too: CA one two five shouldn't be used to diagnose endometriosis.

Sarah: So. Three things for Monday. One. A normal scan or a normal examination doesn't rule out endometriosis, so believe the symptoms. Two. Start treatment, request the transvaginal scan and refer at the same time, not one after another. And three. Leave the CA one two five alone when endometriosis is the question, and ask early whether she's trying to conceive.

Sarah: One thing to reflect on, if you're logging this. Think of the last patient you saw whose period pain kept bringing them back: did anyone say the word endometriosis to them, and did a normal scan end the conversation? The full transcript and the sources are on the episode page. Ben and I are natural AI voices, and what we've said comes from our reviewed Ocean topic. Check your local guidance before you act on it. See you next week.

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