Dr Mathew Leonardi

03/29/2026

This reel shows a negative triangle sign.

In patients with suspected endometriosis, ultrasound is not just about detecting disease. It is about mapping disease extent well enough to guide surgical planning.

The sliding sign is an essential part of assessing the cul-de-sac, but in patients with a retroverted uterus, it may not tell the full story. The triangle sign is a helpful supplemental maneuver.

If pressure is released with the vaginal probe and a small triangle of peritoneal fluid appears between the posterior uterus and the posterior vaginal fornix, that is a positive triangle sign and suggests the cul-de-sac is not obliterated.

If that triangle does not appear, the sign is negative, suggesting obliteration of that space.

A negative triangle sign can therefore be an important clue to posterior compartment disease and surgical complexity.

Dynamic ultrasound matters. Anatomy matters. And subtle signs like this can change how we understand the case before anyone ever enters an operating room.

Have you seen this sign before?

03/27/2026

Postmenopausal endometriosis: myth or reality?

Reality.

(As an aside, there is also another classic pathology seen in these videos - can you identify it? Comment below)

Postmenopausal endometriosis does happen, and it matters.

In this case, there is both an endometrioma and deep endometriosis in postmenopausal patients. That is important because age can push clinicians toward other diagnoses first, especially malignancy when there is an adnexal mass, nodularity, or deep pelvic disease. That concern is appropriate, but endometriosis should still stay on the differential.

This also matters surgically. Even when operating for something else, including gynecologic cancer, endometriosis can change pelvic anatomy, create fibrosis, and make dissection more complex than expected.

The point is not that every postmenopausal mass is endometriosis.
The point is that postmenopausal status does not exclude it.

And whilst postmenopausal endometriosis may still be an explanation for current symptoms, if diagnosed in the postmenopausal years, can be a validating diagnosis for symptoms the patient once had as well, even if they are gone or less impactful now.

Have you seen postmenopausal endometriosis in practice, on imaging, or at surgery?

Comment with what stands out to you in this case, or what you think makes these cases easiest to miss.

Save and share if you find this kind of teaching useful.

03/25/2026

The 17th World Congress on Endometriosis will be held 2–5 June 2027 in Istanbul, Turkey.

This truly global meeting brings together clinicians, researchers and healthcare professionals to advance understanding of endometriosis, improve patient care and accelerate progress in the field.

At WCE2027, you will:
• Engage with the latest research and clinical insights
• Connect with international experts across disciplines
• Exchange ideas that shape future practice and policy
• Build collaborations that extend beyond the Congress

With a world-class scientific program, global faculty and opportunities to strengthen professional networks, WCE2027 is a key moment for the endometriosis community.

Save the date and be part of the global effort to improve outcomes.

🔗 https://www.wce2027.com/

03/23/2026

Finding small nodules of endometriosis is not that hard if you know the right techniques and this one is a must to save and share!

The Posterior Approach!

03/17/2026

Endometriosis impacts one in 10 women worldwide, with many being so deeply impacted by the extreme fatigue, pain, and nausea it causes that day-to-day life becomes challenging.

Yet, in addition an average five-year delay in diagnosis and underfunded research leading to reduced treatment options, even when the condition significantly impact’s one’s ability to work – it’s not recognized as a disability. It’s a pattern we see all too often when it comes to conditions that largely impact women.

Laura, from our community, is looking to change that – and I was glad to share Greens’ support with CBC News as Deputy Leader of Green Party of Canada | Parti vert du Canada. Green leader Elizabeth May is taking her petition to recognize both endometriosis and adenomyosis as disabilities when one’s ability to work is impacted to Parliament.

This case exemplifies why I pushed for the Accessible Canada’s Act’s definition of disability to be used to determine who could receive the Canada Disability Benefit – if it had, people like Laura might be eligible for the support it offers. While the federal government chose to limit the benefit through burdensome and limited definitions then, we can take action now.

Add your voice by signing and sharing the petition, available until July 8, here: https://www.ourcommons.ca/petitions/en/Petition/Details?Petition=e-6929

03/16/2026

For decades, “rectovaginal septum endometriosis” has been treated as accepted anatomical fact. In our recent paper, we revisited that assumption using advanced ultrasound, meticulous laparoscopic assessment, and histopathology in 161 patients. What we found was striking: we found no evidence of endometriosis within the rectovaginal septum itself. Instead, lesions were located in adjacent structures such as the uterosacral ligaments, rectouterine pouch, or bowel. 

Why does that matter? Because anatomy is not just terminology. The language we use shapes how disease is conceptualized, how imaging is interpreted, and how surgery is planned. If the anatomy is wrong, the framework is wrong. 

The take-home message from our team’s study is simple: some long-standing dogma in endometriosis deserves to be challenged. Precision in anatomy leads to precision in diagnosis, surgery, and communication. 

03/14/2026

Endometriomas are rarely “just a cyst.”

When an ultrasound shows an endometrioma, it is often a marker of more extensive disease. Deep endometriosis, adhesions, bowel involvement, ureteral disease, obliterated anatomy. The cyst is frequently the tip of the iceberg.

Yet many patients are still booked for a simple “cystectomy.”

That approach assumes the problem is isolated to the o***y. In many cases, it isn’t.

Operating on an endometrioma without recognizing the broader disease can mean:
• incomplete surgery
• persistent symptoms
• repeat operations
• delayed definitive care

For colleagues: an endometrioma should trigger a careful evaluation for deep endometriosis, not an assumption of isolated ovarian disease.

For patients: if you have been told you have an endometrioma and are being scheduled for a “cystectomy,” it is reasonable to ask whether the surgeon routinely treats complex endometriosis.

Because when it comes to endometriosis surgery, the cyst is often only part of the story.

03/09/2026

There is no single best diagnostic strategy for endometriosis, only the strategy that best fits the individual patient. In our team’s study, we found that patients are not just deciding between imaging and surgery. They are weighing trust, validation, invasiveness, uncertainty, and what a diagnosis actually means in their lives. That is what patient-centred diagnosis really looks like.

Link for study in bio!

02/14/2026

Happy Valentine’s! One year ago today I spent Valentine’s Day with my friends Veronica and Vina, educating hundreds of Filipinos in Davao about endometriosis ultrasound, surgery, setting up a Canadian approach. It was such a fun experience. And now I have friends for life ❤️ and a stunning south sea pearl I treated myself to as a Valentine’s gift 💁🏻‍♂️

01/22/2026

12/21/2025

Wonderful to welcome Dr Claudia Guajardo from Chile for our ultrasound course and a visit. It is truly impressive to witness the global momentum to push gynecology ultrasound forward, especially for endometriosis! The next era of gyn care is going to so much better thanks to the passion and effort of people like Claudia 💛

11/17/2025

AAGL members can network and knowledge share through Special Interest Groups. A SIG is an informal community within our organization that brings together members with a shared focus. These groups create forums to connect people who have similar clinical interests or professional backgrounds in subspecialties within minimally invasive gynecology.

Our new ultrasound and imaging SIG is opening the doors. We are elevating how gynecologists use ultrasound in everyday care. Ultrasound is accessible, reproducible with training, and surgeon-performable. Our SIG will share education, mentoring, and standardized reporting so more clinicians can diagnose fibroids, adenomyosis, endometriosis and more with precision.

January is our webinar month. Stay tuned for the specific date and subject.

Tell us what you want covered in January. Drop topic ideas in the comments.

If you are an AAGL member and want to join, comment JOIN and we will DM you the sign up details.