What are the diagnostic steps for testing for endometriosis?

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Last updated: June 12, 2025 • View editorial policy

From the Guidelines

The most appropriate initial imaging study for suspected endometriosis in an adult patient is either US pelvis transabdominal and US pelvis transvaginal or MRI pelvis without and with IV contrast, as these procedures are equivalent alternatives for providing the necessary clinical information. When diagnosing endometriosis, it is essential to start with a detailed medical history and pelvic examination. Imaging studies such as transvaginal ultrasound or MRI can help identify endometriotic lesions or cysts 1.

Diagnostic Steps

The diagnostic process for endometriosis typically involves:

  • A detailed medical history to understand the patient's symptoms and menstrual cycle
  • A pelvic examination to check for any abnormalities
  • Imaging studies such as transvaginal ultrasound or MRI to identify endometriotic lesions or cysts
  • In some cases, a trial of hormonal medications may be recommended to see if symptoms improve, which can support a presumptive diagnosis 2
  • Laparoscopy with biopsy is considered the gold standard for definitive diagnosis, as it allows for direct visualization and sampling of endometrial tissue growing outside the uterus

Imaging Studies

The choice of imaging study depends on the individual patient's needs and the availability of resources.

  • US pelvis transabdominal and US pelvis transvaginal are suitable alternatives for initial imaging 1
  • MRI pelvis without and with IV contrast can provide more detailed information and is often used for characterization or treatment planning after an indeterminate or negative US 1
  • Expanded protocol transvaginal ultrasound (TVUS) studies have been developed to identify and "map" deep endometriosis, but these studies are not widely available and require special training 2

Importance of Accurate Diagnosis

Accurate diagnosis of endometriosis is crucial to ensure appropriate treatment and management of symptoms.

  • Endometriosis can mimic other conditions such as irritable bowel syndrome or pelvic inflammatory disease, making diagnosis challenging 2
  • A comprehensive diagnostic approach, including medical history, pelvic examination, and imaging studies, can help ensure accurate diagnosis and effective treatment [(1, 2)]

From the Research

Diagnostic Steps for Endometriosis

The diagnostic steps for testing for endometriosis involve a combination of clinical evaluation, physical examination, and imaging tests. The following are the key steps:

  • Physical examination, including a speculum examination and vaginal palpation to evaluate mobility, fixation, and/or tenderness of the uterus and site-specific tenderness in the pelvis 3
  • Pelvic ultrasound and/or pelvic magnetic resonance imaging to evaluate the extent of the endometriosis and to determine whether any urinary tract or bowel procedures might also be required during surgical resection 4, 5, 3
  • Transvaginal ultrasonography to evaluate endometriosis of deep pelvic sites and rule out other causes of pelvic pain 5
  • Laparoscopy with biopsy, which remains the definitive method for diagnosis, although several gynecologic organizations recommend empiric therapy without immediate surgical diagnosis 4, 5, 6

Clinical Diagnosis

Clinical diagnosis of endometriosis can be made based on symptoms, supported by physical examination findings and imaging results 4, 7. The symptoms of endometriosis can vary widely, but common presentations include:

  • Pelvic pain, including dysmenorrhea, nonmenstrual pelvic pain, and dyspareunia 4, 5, 6
  • Infertility 4, 5, 6
  • Period-related gastrointestinal or urinary symptoms 5

Assessment of Quality of Life

Quality of life should be assessed using tools such as the Endometriosis Health Profile-30, its short version EHP-5, or the generic quality of life questionnaire SF-36 3. This assessment can help evaluate the impact of endometriosis on a woman's life and guide management decisions.

Management and Treatment

Management of endometriosis is recommended when it has a functional impact (pain, infertility) or causes organ dysfunction 3. Treatment options include hormonal medications, such as combined oral contraceptives and progestin-only options, which are first-line treatments for symptomatic premenopausal women who do not currently desire pregnancy 4, 5. Surgical removal of lesions, usually with laparoscopy, should be considered if first-line hormonal therapies are ineffective or contraindicated 4, 5, 6.

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Research

Evaluation and management of endometriosis.

Climacteric : the journal of the International Menopause Society, 2023

Research

Endometriosis: A Review.

JAMA, 2025

Research

Endometriosis: Evaluation and Treatment.

American family physician, 2022

Research

Medical Management of Endometriosis.

Clinical obstetrics and gynecology, 2017

Research

Clinical diagnosis of endometriosis: a call to action.

American journal of obstetrics and gynecology, 2019

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.