Endometriosis Diagnosis and Management

Introduction to Endometriosis

Approximately 10% of women with endometriosis are asymptomatic, and noncyclical pain patterns are well-documented presentations of this disease, according to the American College of Radiology 1

Noncyclical pelvic pain, deep dyspareunia, dyschezia, and dysuria may be present without cyclical menstrual pain patterns, as noted by the American College of Radiology and other guideline societies 2
Chronic persistent pain can develop independent of hormonal cycles, particularly in deep infiltrating disease, although the exact correlation is not well-established 2
The American College of Radiology and other societies recommend that a clinical diagnosis of endometriosis can be established based on symptom patterns including dysmenorrhea, dyspareunia, dyschezia, dysuria, chronic pelvic pain, or infertility—cyclical timing is not mandatory 3

Transvaginal ultrasound (expanded protocol) is the initial imaging modality, with sensitivity of 82.5% and specificity of 84.6%, as recommended by the American College of Radiology and other guideline societies 3
MRI pelvis without IV contrast should be obtained if TVUS is inconclusive, showing 90.3% sensitivity and 91% specificity for deep pelvic endometriosis, according to the American College of Radiology and other societies 3
Normal imaging does not exclude endometriosis, particularly superficial peritoneal disease which is poorly detected by all imaging modalities, as noted by the American College of Radiology and other guideline societies 3

Surgical confirmation is no longer required before initiating empiric hormonal treatment, according to the American College of Radiology and other guideline societies 3
First-line hormonal medications (combined oral contraceptives or progestin-only options) should be offered to symptomatic premenopausal women based on clinical suspicion alone, as recommended by the American College of Radiology and other societies 5

The American College of Radiology recommends not dismissing endometriosis because pain is not cyclical or menstrual-related 1
The American College of Radiology and other societies note that pain severity does not correlate with disease stage, and therefore, minimal symptoms should not be assumed to mean minimal disease 2