Endometriosis Diagnosis

Endometriosis diagnosis starts with a careful history and focused pelvic exam. We listen for cyclical pelvic pain, pain with intercourse, bowel or bladder symptoms, and infertility. Expert transvaginal ultrasound is the first line imaging to look for endometriomas and signs of deep disease. Pelvic MRI helps map lesions behind the uterus, along the uterosacral ligaments, rectovaginal septum, bowel, and bladder. Blood tests such as CA 125 are nonspecific and cannot diagnose endometriosis.

Colonoscopy is usually normal unless bowel mucosa is involved, so it is used to rule out other causes of bleeding. Many patients begin treatment based on consistent symptoms plus imaging. Laparoscopy with biopsy remains the definitive test when imaging is inconclusive, when severe pain persists despite medical therapy, or when surgery is planned for pain or fertility goals.

What are the steps to diagnosing endometriosis?

Endometriosis diagnosis requires three levels of diagnostic evaluation:

Step 1: endometriosis diagnosing pre-surgery

The initial stage is a clinical examination and appropriate testing, which includes a pelvic examination and ultrasound. During this time, patients thoroughly recount their current symptoms. The doctor intently listens in order to build the trust necessary to facilitate long-time care.

Upon physical examination, findings such as the cervix, pelvic side, and posterior thigh tenderness, which can radiate as far back to the cervix at the rectal wall, serve as key signs of the presence of endometriosis lesions and their possible locations. Sonogram technology can help confirm the cause of this tenderness. If you have diffuse pelvic tenderness, a rectal exam may also be necessary as it is important to determine if there is localized rectovaginal tenderness, a key sign of rectovaginal disease.

Step 2: endometriosis diagnosing during surgery

The second stage is a visual diagnosis by recognition of endometriotic lesions through laparoscopy. This will take place in the operating room, during laparoscopic surgery.

Step 3: endometriosis diagnosing after surgery

The final formal diagnosis of endometriosis requires the pathologic examination of lesions under a microscope. Surgical specimens obtained through laparoscopic deep excision surgery must be sent off to the lab. It usually takes a few days following your surgery to assess those specimens. 

What testing takes place pre-surgery?

Pelvic exam

This physical examination of a patient’s pelvis and pelvic organs is part of any fully comprehensive gynecological exam. During this exam, a physician will look for any and all points of pelvic tenderness. Through a pelvic exam, your doctor will be able to gain a better understanding of your symptoms and any pain you may be experiencing. If your physician specializes in endometriosis, they may even be able to diagnose conditions like frozen pelvis.

Transvaginal ultrasound

An ultrasound is a safe and painless technique that uses sound waves to produce detailed images of the inside of the body. The doctor inserts a small probe, called a transducer into your vagina in a way similar to the way you would insert a tampon. Sound waves will then pass harmlessly from the transducer through the skin. They then bounce off certain organs and tissue in the body and create “echoes.”

These echoes reflect back to the transducer, which converts them into electrical signals in order to produce an image. The images are viewed in real-time on a monitor and are also recorded and photographed for your physician to review. It is important to note that this test can be performed during menstruation.

Sonohysterography

During this imaging technique, the doctor injects fluid through the cervix into the uterus. They then use ultrasound to produce images of the uterine cavity. The use of this fluid provides more detail of the inside of the uterus than ultrasound alone. This procedure is performed to find the underlying causes of abnormal uterine bleeding, miscarriage, and infertility. It can help detect abnormal uterine growths like fibroids or polyps, uterine scarring, and abnormal uterine shape.

This procedure cannot be scheduled during your menstrual cycle or when you are experiencing abnormal bleeding. In cases of abnormal bleeding, the test can take place as soon as the bleeding stops. After this exam, you may have some cramping, spotting, and watery discharge. The procedure is generally safe, but in rare cases, there is a risk of pelvic infection.

Magnetic resonance imaging (MRI)

MRI is a non-invasive imaging technique that produces a strong magnetic field and radio waves. These are used to create detailed images of the tissues, organs, and other areas. 

An MRI differs from a CT scan as it uses low-frequency magnetic fields as opposed to the high-energy X-rays that a CT scan uses, which often puts patients at risk of radiation exposure. An MRI produces much more comprehensive and detailed imaging than an ultrasound, as it often encompasses the entire body. However, an MRI is much more expensive than an ultrasound. Moreover, MRI testing does not take place in the office of your everyday primary care physician or gynecologist but you need a referral. 

Nevertheless, MRI testing serves as a very useful tool for your doctor to have an idea of the extent of your disease. So, it is very common for your specialist to ask for an MRI test prior to surgical treatment. 

What testing takes place during surgery?

Hysteroscopy

Hysteroscopy is an imaging technique performed in the operating room in order to view the lining of the uterus (endometrium). This is done using a thin tool with a light and camera (the hysteroscope) attached to its tip. The doctor gently inserts this into the vagina, through the cervix, and into the uterus. With this technique, a surgeon will be able to see if there is any uterine cause for heavy menstrual bleeding, pelvic pain, or infertility. This is very useful in cases of adenomyosis.

Laparoscopy

Laparoscopy allows the visualization of the abdomen and pelvic cavity through an instrument known as the laparoscope. Performed under general anesthesia, the laparoscope is inserted through small incisions made in the abdominal and pelvic cavity. The surgeon then sutures these back together after surgery. The goal of this technique is to make small incisions in order to ensure minimal invasion. This method allows your surgeon to inspect the abdominal and pelvic regions (and beyond, as needed) to diagnose and subsequently remove endometrial lesions, utilizing his or her surgical modality and tool of choice like a laser or excision clippers.

Why is endometriosis diagnosing difficult?

Diagnosing endometriosis is difficult because symptoms are diverse and often mimic other disorders such as IBS, interstitial cystitis, pelvic floor dysfunction, and adenomyosis. Pain severity does not always match lesion size, and some patients have minimal findings on exam. Standard labs are nonspecific, and colonoscopy often appears normal. Expertise matters. Deep infiltrating disease requires specialized ultrasound protocols and high quality MRI to be seen reliably.

Many people have learned to normalize menstrual pain, delaying care, and adolescents may present atypically. Access barriers, fragmented care, and variable imaging quality add to the challenge. A multidisciplinary approach with experienced sonographers, radiologists, gynecologic surgeons, and when needed colorectal or urology input improves accuracy and speeds treatment.

How do doctors confirm endometriosis?

Doctors confirm endometriosis by combining a consistent symptom pattern with targeted imaging, then using laparoscopy with histology when needed. Transvaginal ultrasound by an experienced sonographer can identify ovarian endometriomas and suggest deep lesions. Pelvic MRI refines the map by showing depth and organ involvement. If findings align with symptoms, we may start medical therapy without immediate surgery.

Laparoscopy confirms the diagnosis when imaging is unclear, when complications are suspected, or when excision is planned to improve pain or fertility. During surgery we remove or sample lesions and send tissue for pathology. The confirmation method depends on your goals, the severity of symptoms, and how clearly imaging defines disease.

Endometriosis diagnosis timeline

The endometriosis diagnosis timeline varies. A typical path begins with primary or gynecologic evaluation, followed by expert transvaginal ultrasound. If symptoms suggest deep disease, pelvic MRI is added to guide treatment choices. Many patients try medical therapy first, often for several months, to assess pain response and quality of life. If pain persists, or fertility is a priority, referral to an endometriosis specialist and a colorectal or urology colleague may follow.

Surgical confirmation and excision are considered when imaging is inconclusive, when there is organ compromise, or when medical therapy is inadequate. Delays occur when symptoms are normalized, when access to specialist imaging is limited, or when overlapping conditions obscure the pattern. Prompt referral shortens the journey.

Can you live with endometriosis without treatment?

It is possible to live with endometriosis without treatment, but it can lead to worsening symptoms over time. Many individuals with endometriosis experience chronic pain, heavy periods, and fertility issues that may interfere with daily life.

Without treatment, these symptoms may become more severe, and the condition may progress, leading to complications like adhesions, organ damage, or infertility. Treatment options, such as pain management, hormonal therapy, or surgery, can help alleviate symptoms and prevent further complications, improving quality of life. It’s important to discuss symptoms with a doctor to determine the best approach for managing the condition.

Can endometriosis be diagnosed without surgery?

While laparoscopy, a surgical procedure, is definitely the most conclusive way to diagnose endometriosis, sometimes doctors can strongly suspect it through other methods first.

Often, they’ll rely on a combination of things: your medical history, the symptoms you’re experiencing (like pelvic pain or heavy periods), pelvic exams, and even ultrasounds or MRI scans.

These imaging techniques can be really helpful for spotting cysts or other signs that suggest the condition might be present, though it’s important to remember they can’t give you a definitive diagnosis on their own. For that, a biopsy (which can only be obtained during surgery) remains the most reliable method to confirm endometriosis.

However, based on all these clinical findings, your doctor might decide that starting treatment without immediate surgery is the best path forward for you in some cases.

How accurate is ultrasound for detecting endometriosis?

Ultrasound can be useful in detecting endometriosis, but its accuracy is limited. It is especially effective for identifying endometriomas, which are cysts filled with endometrial tissue, but it may not detect other forms of endometriosis, such as those involving the pelvic lining or organs like the bowel.

While transvaginal ultrasound is commonly used to assess for these cysts, it cannot definitively diagnose endometriosis. For a more accurate diagnosis, laparoscopy is typically required. Ultrasound can, however, help doctors rule out other conditions and suggest the need for further diagnostic procedures.

How is endometriosis formally diagnosed?

Despite advances in diagnostic technologies and other presurgical imaging tests that help determine, a confirmation of endometriosis requires a surgical biopsy. This is commonly obtained through minimally invasive laparoscopy.

Are there other ways to formally diagnose endometriosis?

Ultrasounds, MRI, CT scans, and endometrial biopsy samples can be part of a diagnostic workup. But to date, anything less than surgical confirmation of endometriosis is considered uncertain. There are also no specific blood tests to diagnose endometriosis.

Our approach to diagnosing endometriosis pre-surgery

Physical exam

There are a variety of tests that we perform to diagnose endometriosis before a patient has surgery.

After we note your symptoms, history, and complaints during a consultation, we will conduct a thorough physical exam. This consists of a comprehensive pelvic exam, which includes inspecting the cervix, checking for neuropathy in your lower back and legs, assessing costovertebral angle (CVA) tenderness, and evaluating the upper vagina with digital palpation. We evaluate the nodularity, thickening, and shortening of the uterosacral ligament, rectovaginal, cul-de-sac, and lateral vaginal walls in this manner. The tenderness of these areas is significant in measuring the extent of the disease.

We will also perform a gentle, single digital pelvic bimanual examination. In addition, we also note the mobilization and tenderness of the cervix to touch during this exam (CMT, or cervical motion tenderness). We will then evaluate the anterior and posterior cervix and the upper vagina with digital palpation.

Transvaginal ultrasound

For patients experiencing painful bowel movements, we perform a transvaginal rectovaginal sonogram (transvaginal ultrasonography or transvaginal ultrasound) on top of a physical exam. Transvaginal ultrasound performed after a bowel preparation improves the ability to properly diagnose intestinal lesions. It also provides invaluable details including which layers of the intestine the disease affects and the distance between the lesion(s) and the anal border. We carefully evaluate the uterine walls, endometrial canal, and endometrial cavity for the presence of adenomyosis, fibroids, and polyps. We then scan the cul-de-sac and rectovaginal septum. Finally, it is important to inspect the ovaries. Having treated women with endometriosis for nearly three decades, we strongly believe that ovarian cancer is directly associated with endometriosis. Transvaginal ultrasounds have consistently proven to be the most promising imaging method for the routine screening of ovarian cancer. It is also very effective in screening for endometriosis.

Sonohysterography

We use sonohysterography along with an ultrasound to produce detailed images of the uterine cavity in order to aid in identifying endometrial lesions of submucosal fibroids and polyps particularly in patients with a history of infertility and heavy periods, regardless of their pain.

Our approach to diagnosing endometriosis during surgery

Hysteroscopy

Before any excision surgery, we conduct a hysteroscopy in order to visualize the lining of the uterus (endometrium). This will allows us to see if there is any uterine cause for heavy menstrual bleeding, pelvic pain, or infertility.

Laparoscopy

Following your hysteroscopy, we make small incisions into the abdominal and pelvic region. We then insert a laparoscope into the incision sites. The images appear on two monitors, one for the surgeon and one for the attending resident. We do all our surgeries via laparoscopy. This allows us to clearly visualize any suspected endometriosis lesions.

ABC technique (™)

The Aqua Blue Contrast Technique (ABC) is a patented surgical technique that we use during laparoscopic excision surgery in order to clearly visualize endometriosis scar tissue with an aqua blue contrast solution. While some lesions may be invisible to the typical surgeon using laparoscopic light, the ABC technique eliminates light reflection and allows the surgeon to visualize, and thus identify and fully excise endometriosis lesions. This method ensures that we identify all areas of endometriosis development throughout the body. This diagnostic tool is strictly unique to us.

So many patients diagnosed with endometriosis undergo multiple surgeries, only for their symptoms to return. Often, this occurs because the surgeon has not identified every endometriosis lesion and left behind a considerable amount of scar tissue. In order to ensure a thorough and successful surgery, it is crucial for you to ask the right questions about your surgery, and to learn how your surgeon will identify and excise endometrial lesions.

Using common diagnostic tools such as ultrasound, MRI, and hysteroscopy, in combination with our unique method of laparoscopy using the ABC technique, we ensure that no visible endometriosis lesion goes undetected. But on top of these diagnostic tools, the first step in identifying your endometriosis is through proper communication.