Diagnosis & Therapy

Image-based diagnosis

Is the future of endometriosis diagnosis image-based?

It could be possible to treat appropriately presenting patients with certain ultrasonography markers without performing laparoscopy, according to this expert
By Lila O’Connor, featuring Steven R. Goldstein, MD

The ObGyn specialty is talking about endometriosis.1 Why? Because the condition causes pain, often severe, in affected patients. Because diagnosis can take an average of 8 years.Because 1 in 10 US women between the ages of 15 and 44 have it (6.5 million American women).1 Because recent findings from phase 3 trials of a promising oral therapy specific to endometriosis (where one has not existed in the past) show promise.3

There is no doubt that endometriosis is a difficult disease process, says Steven Goldstein, MD, Professor of Obstetrics and Gynecology at New York University School of Medicine and Director of Gynecologic Ultrasound at New York Medical Center. “It has a tremendous impact on pain and quality of life, as well as on fertility and normalcy of pelvic organs.”

As with any disease process, diagnosis is crucial. “Certainly, clinicians have been taught that laparoscopy is the gold standard for diagnosis. There was a time when, without laparoscopic proof, either visually or histologically at the time of surgery, one would never have accepted a diagnosis of endometriosis.”


Perspectives on Endometriosis Management

However, “I think those times have changed,” says Goldstein.

Evidence of ultrasound’s diagnosing accuracy
A critical component for diagnosing endometriosis includes moderate to severe chronic pelvic pain that is unrelated to menstruation and unresponsive to NSAIDs and oral contraceptive pills for at least 6 months, says Goldstein. When this chronic pain is coupled with dysmenorrhea and dyspareunia, it is highly suggestive that the diagnosis is endometriosis, he says. Of course, it is important to rule out adhesions from other sources and dysmenorrhea, he advises.

An interesting question is, Goldstein points out, can the presence of these clinical factors be coupled with ultrasound findings to presumptively treat endometriosis with oral medical therapy—when such therapy may be available?

In a study published in the British Journal of Obstetrics and Gynecology, Okaro and colleagues described hard and soft markers of endometriosis on ultrasonography.4 Hard markers included endometrioma or hydrosalpinx. Soft markers included reduced ovarian mobility and site-specific pelvic tenderness. Along with chronic pelvic pain, the probability of endometriosis was 100% among women with ultrasonographic presence of hard markers and 73% among those with the presence of soft markers.4

Transvaginal ultrasound of a 34-mm endometriotic lesion involving the serosa of the rectosigmoid junction.

Source: Papadopoulos D, Coppola F, Valerio D, et al; Bologna/IT. European Society of Radiology, ECR 2015. Poster No. B-0587. doi: 10.1594/ecr2015/B-0587.

MRI’s role

When considering this concept of image-based diagnosis it is important to differentiate between endometriosis that is early-stage peritoneal disease and that which is late-stage deep infiltrating disease, points out Goldstein. Magnetic resonance imaging may have value in cases of late-stage deep infiltrating disease, he says.




  1. Gellhaus T. It’s time we talk about endometriosis. March 21, 2017. Accessed April 4, 2017.
  2. Barbieri RL. Why are there delays in the diagnosis of endometriosis? Endometriosis Journey website. Accessed April 4, 2017.
  3. Taylor HS, Giudice LC, Lessey BA, et al. Treatment of endometriosis-associated pain with elagolix, an oral GnRH antagonist. N Engl J Med. 2017 May 19. doi: 10.1056/NEJMoa1700089.
  4. Okaro E, Condous G, Khalid A, et al. The use of ultrasound-based ‘soft markers’ for the prediction of pelvic pathology in women with chronic pelvic pain—can we reduce the need for laparoscopy? Br J Obstet Gynecol. 2006;113(3):251–256.

Endometriomas and deep infiltrating endometriosis on magnetic resonance imaging.

Source: Granados Palacio LF, Pernas JC, Menso MM, Hernández JA; Barcelona/ES. European Society of Radiology, ECR 2014. Poster C-0537. doi: 10.1594/ecr2014/C-0537.