Your Pelvic Ultrasound Is Clear (or So They Believe)—Now What?
Why a clear ultrasound isn’t always the answer.
Receiving a “clear” pelvic ultrasound when you’re still in pain can feel frustrating and defeating. A clear result often doesn’t mean there’s nothing wrong. It just means the tools used couldn’t find the root cause or the issue. This is particularly true for conditions like endometriosis, which rarely appear on standard ultrasounds unless the radiologist is formally trained in identifying superficial endo and such conditions. I can say that diagnosing endometriosis is happening more and more, which is great to see so more patients can get the care they deserve (if the diagnosis on US leads to a specialist who is trained). Here are some examples:
Steps to take after receiving clear ultrasound results:
Start the conversation with your doctor
The first thing to do is go back to your doctor and get specific about your symptoms. Don’t hold back! Seriously. Describe the type of pain, when it happens plus how it’s impacting your life. This helps them understand how serious your situation is.
From there you might want to explore more advanced imaging like an MRI with contrast. These scans are better at detecting conditions like deep infiltrating endometriosis, adenomyosis or fibroids, which might have been missed on the ultrasound. With conditions like endometriosis, MRI is another modality that is based on quality of scan and requires a skilled radiologist to review.
Good follow-up questions to ask after a clear ultrasound result is:
- If the ultrasound didn’t reveal any issues, what are the next steps to investigate the source of my pain?
- Could advanced imaging like an MRI or CT scan provide more insight?
- Are there any conditions that wouldn’t show up on an ultrasound but align with my symptoms?
- Should I be referred to a gynecologist or pelvic pain specialist for further evaluation?
Know the limitations to imaging
Here’s something important to remember: not everything shows up on imaging. Conditions like endometriosis, adhesions or even abdominal vascular compressions can go undetected. This holds true to many other health conditions. If you’re hitting a wall, ask your doctor about other diagnostic methods. Surgical options like a laparoscopy might be necessary for a definitive diagnosis of some pelvic related conditions.
You might also explore specialized imaging techniques. For example, a doppler ultrasound or CT angiography can help diagnose conditions like pelvic congestion syndrome or May-Thurner syndrome which are often overlooked but can contribute to chronic pelvic pain.
| MRI with Contrast | CT Scans or Doppler Ultrasound: |
|---|---|
|
Offers a detailed view of pelvic organs and can help detect hidden conditions. |
These are less common but can identify abnormalities or vascular issues that contribute to pelvic pain. |
Seeking out the right specialist… for the additional imaging
Now, this part can feel tricky because finding the right specialist isn’t always straightforward. Some areas have long waitlists, limited referrals or even insurance barriers (USA). But here’s a tip: ask your doctor if they know any imaging centers or radiologists who specialize in detecting complex conditions like endometriosis. If they don’t, consider larger medical centers or teaching hospitals. They often have the technology and staff with the expertise you need. Additionally… If you search for your suspected condition on social groups, these communities can sometimes provide recommendations or share experiences that might help guide you in the right direction.
| Pelvic Floor Physical Therapists | Pain Specialists or Neurologists | MIGS Gynecologists or Urogynecologists |
|---|---|---|
|
They can assess whether muscle tension, weakness and/or nerve entrapment is contributing to your pain.
|
Nerve-related pain might require treatments like nerve blocks, medications, or neuromodulation.
|
Experts in UROGYN or OBGYN with a fellowship in minimally invasive gynecologic surgery + years of experience in gynecological surgeries who can evaluate conditions that often don’t show on imaging, like endometriosis or adhesions. |
Alternative approaches for managing pain
At the end of the day. if you’ve been told everything is “normal,” but you know something is wrong, it might be time to look into other options. Pelvic floor physiotherapy is a fantastic place to start. Tight or overactive pelvic floor muscles can cause pain and a skilled physiotherapist can help release tension and improve function.
If your pain feels sharp, burning or shooting it might be nerve-related. In that case, consulting a neurologist or pain specialist could help uncover issues with nerves like the pudendal nerve.
Pain management specialists can also provide techniques like nerve blocks, trigger point injections or medications that help reduce chronic pain. Even complementary methods like acupuncture, mindfulness or yoga can make a difference.
Treatments + Therapies
Most frequent modalities used
Pelvic Floor Physiotherapy can help. With CPP, the muscles of the pelvic floor can become hypersensitive and tight affecting bladder, bowel and sexual function. Treatment can include pain education, manual release of the pelvic floor in a non-painful way, and breathing techniques.
Mental health is a critical component of care when you live with chronic pelvic pain, regardless of the underlying cause.The psychological side effects can be as debilitating as the pain itself. This is what makes CPP such a complex condition. We must seek help medically and/or from our support systems. It is not shameful to speak to someone who can safely support you. A therapist is a great place to start.
Gabapentin, Pregabalin (Lyrica): Evidence supports use for neuropathic pain.
Gabapentin + Amitriptyline used together: Evidence supports its use for neuropathic pain. Small study in women with chronic pelvic pain showed combination was more effective than amitriptyline alone.
Nonsteroidal anti-inflammatory drugs (Aleve, Advil): Benefits inflammation and dysmenorrhea (painful menstrual cramps).
Hormonal (Oral contraceptives, gonadotropin-releasing hormone (GnRH) agonists): Evidence of benefit for cyclic pain in women but limited evidence for noncyclic pelvic pain.
Tricyclic Antidepressants (Amitriptyline): Evidence supports use for neuropathic pain.
Opioids should only be considered for long-term management of pain when other options have been exhausted. Referral to a pain management specialist should be considered.
You can use alternative medicine alone or combined with medications and they can be a powerful tool in learning to live with chronic pain.
Examples of alternative medicine for chronic pain can include massage therapy, magnetic therapy, Reiki, accupuncture, herbal medicine, and mindfulness.
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Another powerful tool is learning about pain science. Understanding how pain works (particularly chronic pain) can give you back a sense of control. Pain doesn’t always equal damage and in cases of persistent pain, your nervous system might be in overdrive, interpreting normal signals as threatening. Resources like Tame the Beast by Lorimer Moseley or pain program courses at local universities or online courses about pain neuroscience can help you reframe your experience and find new ways to manage your symptoms.
At the end of the day, a clear ultrasound doesn’t mean you’re fine. It just means the tools couldn’t find the issue. Your pain is real (remember that!) and you know your body better than anyone. Sometimes it takes persistence and the right questions to uncover the source of the problem. You deserve answers and you deserve care that listens to and validates your experience.If you’re not getting the support you need, don’t hesitate to:
- Seek a second opinion.
- Look into care at larger medical centers or teaching hospitals with pain programs and specialized technology and staff.
- Reach out to support groups for recommendations.
Remember, a clear ultrasound doesn’t mean you’re fine because it just means the tools used couldn’t find the issue.
Knuttinen MG, Xie K, Jani A, Palumbo A, Carrillo T, Mar W. Pelvic venous insufficiency: imaging diagnosis, treatment approaches, and therapeutic issues. AJR Am J Roentgenol. 2015;204(2):448-458. doi:10.2214/AJR.14.12709
Pascoal E, Wessels JM, Aas-Eng MK, et al. Strengths and limitations of diagnostic tools for endometriosis and relevance in diagnostic test accuracy research. Ultrasound Obstet Gynecol. 2022;60(3):309-327. doi:10.1002/uog.24892
