Noninvasive Imaging Diagnostics for Endometriosis

Abstract

Endometriosis is a prevalent gynecological condition affecting approximately 10% of women of reproductive age and up to 50% of those with infertility. It is characterized by the presence of endometrial-like tissue outside the uterine cavity. Despite its high prevalence, diagnosis is often delayed by up to 10 years from symptom onset, partly due to the historical lack of accurate, noninvasive diagnostic tools. Although major reproductive societies continue to define videolaparoscopy as the gold standard for diagnosing endometriosis, it does not reliably predict disease extent. Consequently, once a presumptive diagnosis is established, accurate and detailed imaging is invaluable for patient management. Comprehensive endometriosis mapping enhances surgical planning, facilitates appropriate triage to specialized centers for advanced disease, and improves patient counseling regarding potential complications and risks.

Keywords

endometriosis - diagnosis - noninvasive - imaging - magnetic resonance imaging - ultrasound

Publication History

Article published online:
20 January 2026

• References

• 1 VanBuren W, Feldman M, Shenoy-Bhangle AS. et al. Radiology state-of-the-art review: endometriosis imaging interpretation and reporting. Radiology 2024; 312 (03) e233482
• 2 Colak C, Chamie LP, Youngner J. et al. MRI features of pelvic nerve involvement in endometriosis. Radiographics 2024; 44 (01) e230106
• 3 Kilcoyne A, O'Shea A, Gervais DA, Lee SI. Hysterosalpingography in endometriosis: performance and interpretation. Abdom Radiol (NY) 2020; 45 (06) 1680-1693
• 4 Roditis A, Florin M, Rousset P. et al. Accuracy of combined physical examination, transvaginal ultrasonography, and magnetic resonance imaging to diagnose deep endometriosis. Fertil Steril 2023; 119 (04) 634-643
• 5 Andres MP, Arcoverde FVL, Souza CCC, Fernandes LFC, Abrão MS, Kho RM. Extrapelvic endometriosis: a systematic review. J Minim Invasive Gynecol 2020; 27 (02) 373-389
• 6 Young SW, Jha P, Chamié L. et al. Society of radiologists in ultrasound consensus on routine pelvic US for endometriosis. Radiology 2024; 311 (01) e232191
• 7 Chamié LP. Ultrasound evaluation of deeply infiltrative endometriosis: technique and interpretation. Abdom Radiol (NY) 2020; 45 (06) 1648-1658
• 8 Skinner CM, Kuijer RG. The role of self-compassion in protecting psychological wellbeing and health-related quality of life in those with endometriosis: a prospective study. J Psychosom Res 2025; 196: 112322
• 9 Chamié LP, Ribeiro DMFR, Tiferes DA, Macedo Neto AC, Serafini PC. Atypical sites of deeply infiltrative endometriosis: clinical characteristics and imaging findings. Radiographics 2018; 38 (01) 309-328
• 10 Chamié LP, Blasbalg R, Pereira RMA, Warmbrand G, Serafini PC. Findings of pelvic endometriosis at transvaginal US, MR imaging, and laparoscopy. Radiographics 2011; 31 (04) E77-E100
• 11 Tomassetti C, Johnson NP, Petrozza J. et al; International Working Group of AAGL, ESGE, ESHRE and WES. An international terminology for endometriosis, 2021. Facts Views Vis ObGyn 2021; 13 (04) 295-304
• 12 Guerriero S, Condous G, van den Bosch T. et al. Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group. Ultrasound Obstet Gynecol 2016; 48 (03) 318-332
• 13 Kamergorodsky G, Ribeiro PAA, Galvão MAL. et al. Histologic classification of specimens from women affected by superficial endometriosis, deeply infiltrating endometriosis, and ovarian endometriomas. Fertil Steril 2009; 92 (06) 2074-2077
• 14 Brosens I, Puttemans P, Campo R, Gordts S, Brosens J. Non-invasive methods of diagnosis of endometriosis. Curr Opin Obstet Gynecol 2003; 15 (06) 519-522
• 15 Goncalves MO, Siufi Neto J, Andres MP, Siufi D, de Mattos LA, Abrao MS. Systematic evaluation of endometriosis by transvaginal ultrasound can accurately replace diagnostic laparoscopy, mainly for deep and ovarian endometriosis. Hum Reprod 2021; 36 (06) 1492-1500
• 16 Abrao MS, Andres MP, Gingold JA. et al. Preoperative ultrasound scoring of endometriosis by AAGL 2021 endometriosis classification is concordant with laparoscopic surgical findings and distinguishes early from advanced stages. J Minim Invasive Gynecol 2023; 30 (05) 363-373
• 17 Nisenblat V, Bossuyt PMM, Farquhar C, Johnson N, Hull ML. Imaging modalities for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev 2016; 2 (02) CD009591
• 18 Goncalves Mda C, Podgaec S, Dias Jr JA, Gonzalez M, Abrao MS. Transvaginal ultrasonography with bowel preparation is able to predict the number of lesions and rectosigmoid layers affected in cases of deep endometriosis, defining surgical strategy. Hum Reprod 2010; 25 (03) 665-671
• 19 Woo S, Suh CH, Kim H. Diagnostic performance of computed tomography for bowel endometriosis: a systematic review and meta-analysis. Eur J Radiol 2019; 119: 108638
• 20 Bazot M, Bharwani N, Huchon C. et al. European society of urogenital radiology (ESUR) guidelines: MR imaging of pelvic endometriosis. Eur Radiol 2017; 27 (07) 2765-2775
• 21 Kido A, Himoto Y, Moribata Y, Kurata Y, Nakamoto Y. MRI in the diagnosis of endometriosis and related diseases. Korean J Radiol 2022; 23 (04) 426-445
• 22 Lorusso F, Scioscia M, Rubini D. et al. Magnetic resonance imaging for deep infiltrating endometriosis: current concepts, imaging technique and key findings. Insights Imaging 2021; 12 (01) 105
• 23 Fiaschetti V, Crusco S, Meschini A. et al. Deeply infiltrating endometriosis: evaluation of retro-cervical space on MRI after vaginal opacification. Eur J Radiol 2012; 81 (11) 3638-3645
• 24 Scardapane A, Bettocchi S, Lorusso F. et al. Diagnosis of colorectal endometriosis: contribution of contrast enhanced MR-colonography. Eur Radiol 2011; 21 (07) 1553-1563
• 25 Loubeyre P, Copercini M, Frossard JL, Wenger JM, Petignat P. Pictorial review: rectosigmoid endometriosis on MRI with gel opacification after rectosigmoid colon cleansing. Clin Imaging 2012; 36 (04) 295-300
• 26 Chassang M, Novellas S, Bloch-Marcotte C. et al. Utility of vaginal and rectal contrast medium in MRI for the detection of deep pelvic endometriosis. Eur Radiol 2010; 20 (04) 1003-1010
• 27 Uyttenhove F, Langlois C, Collinet P. et al. Deep infiltrating endometriosis: should rectal and vaginal opacification be systematically used in MR imaging?. Gynécol Obstét Fertil 2016; 44 (06) 322-328
• 28 Hottat N, Larrousse C, Anaf V. et al. Endometriosis: contribution of 3.0-T pelvic MR imaging in preoperative assessment—initial results. Radiology 2009; 253 (01) 126-134
• 29 Mori S, Zhang J. Principles of diffusion tensor imaging and its applications to basic neuroscience research. Neuron 2006; 51 (05) 527-539
• 30 Manganaro L, Porpora MG, Vinci V. et al. Diffusion tensor imaging and tractography to evaluate sacral nerve root abnormalities in endometriosis-related pain: a pilot study. Eur Radiol 2014; 24 (01) 95-101
• 31 Porpora MG, Vinci V, De Vito C. et al. The role of magnetic resonance imaging-diffusion tensor imaging in predicting pain related to endometriosis: a preliminary study. J Minim Invasive Gynecol 2018; 25 (04) 661-669
• 32 Pontes Fernandez CFR, Oliveira BC, Franco IP. et al. Imaging anatomy of the lateral pelvic compartment applied to endometriosis. Abdom Radiol (NY) 2025; 50 (02) 936-952
• 33 Quesada J, Härmä K, Reid S. et al. Endometriosis: a multimodal imaging review. Eur J Radiol 2023; 158: 110610
• 34 Yoon JH, Choi D, Jang K-T. et al. Deep rectosigmoid endometriosis: “mushroom cap” sign on T2-weighted MR imaging. Abdom Imaging 2010; 35 (06) 726-731
• 35 Busard MPH, van der Houwen LEE, Bleeker MCG. et al. Deep infiltrating endometriosis of the bowel: MR imaging as a method to predict muscular invasion. Abdom Imaging 2012; 37 (04) 549-557
• 36 Xiao L, White D, Kruger LF. et al. Thoracic endometriosis syndrome: imaging findings and the value of a dedicated MRI protocol. Abdom Radiol (NY) 2025; 50 (09) 4423-4436
• 37 Jung SI, Kim YJ, Jeon HJ, Jeong K-A. Deep infiltrating endometriosis: CT imaging evaluation. J Comput Assist Tomogr 2010; 34 (03) 338-342
• 38 Sivajohan B, Elgendi M, Menon C, Allaire C, Yong P, Bedaiwy MA. Clinical use of artificial intelligence in endometriosis: a scoping review. NPJ Digit Med 2022; 5 (01) 109
• 39 Abrão MS, Podgaec S, Pinotti JA, de Oliveira RM. Tumor markers in endometriosis. Int J Gynaecol Obstet 1999; 66 (01) 19-22