A New Way of Diagnosing Endometriosis?

For years, endometriosis has been one of the most underdiagnosed and misunderstood conditions affecting women and people assigned female at birth. Characterized by symptoms such as chronic pelvic pain, painful periods, pain during intercourse, bowel or bladder symptoms, and infertility, endometriosis has historically been associated with significant delays in diagnosis. Although awareness has improved, many people still wait an average of 7 to 10 years before receiving a diagnosis.¹˒²

Fortunately, advances in imaging are changing the way endometriosis is diagnosed. Today, transvaginal ultrasound (TVUS) with endometriosis mapping has emerged as a valuable, non-invasive tool that can identify many forms of endometriosis without requiring surgery.³

What Is Endometriosis Mapping?

Endometriosis mapping is an advanced transvaginal ultrasound performed by clinicians with specialized training in identifying the characteristic features of endometriosis.

Unlike a routine pelvic ultrasound, which may miss many endometriosis lesions, this specialized examination systematically evaluates the pelvis for signs of:³˒⁴

• Deep infiltrating endometriosis (DIE)
• Endometriomas (ovarian endometriosis cysts)
• Pelvic adhesions
• Distortion of normal pelvic anatomy
• Reduced organ mobility, including the “sliding sign”

Most specialists follow the standardized International Deep Endometriosis Analysis (IDEA) protocol, which was developed to improve consistency and diagnostic accuracy across imaging centres.⁴

How Accurate Is It?

Research over the past decade has shown that expert-performed TVUS is highly accurate for detecting deep infiltrating endometriosis and ovarian endometriomas.⁵

A large systematic review found that TVUS demonstrates high sensitivity and specificity for many deep endometriosis locations, particularly involving the rectosigmoid bowel, bladder, and rectovaginal septum when performed by experienced operators.⁵

However, TVUS remains less sensitive for superficial peritoneal endometriosis, meaning a normal ultrasound does not completely exclude the condition.³˒⁵ Clinical symptoms and physical examination remain important parts of the diagnostic process.

Why This Matters

Historically, laparoscopic surgery was considered the definitive way to diagnose endometriosis. However, international clinical guidelines have evolved.

Current recommendations from the European Society of Human Reproduction and Embryology (ESHRE) support using transvaginal ultrasound or MRI as first-line diagnostic imaging in patients with suspected endometriosis. Imaging findings, together with symptoms and clinical evaluation, can often provide enough information to begin treatment without requiring immediate surgery.³

This represents an important shift in care.

Earlier diagnosis may help reduce years of uncertainty, allow patients to begin symptom management sooner, improve surgical planning when needed, and reduce unnecessary diagnostic procedures.¹˒³

What Should You Ask Your Healthcare Provider?

Because endometriosis mapping requires additional training, not every ultrasound clinic performs this examination.

If you’re seeking evaluation for possible endometriosis, consider asking:

• Do you perform transvaginal ultrasound using the IDEA endometriosis mapping protocol?
• Does the sonographer have experience evaluating deep infiltrating endometriosis?
• Would MRI be appropriate if my ultrasound is inconclusive?
• How will the imaging results influence my treatment plan?

The Bottom Line

Endometriosis mapping with transvaginal ultrasound is changing how clinicians diagnose endometriosis. While it does not detect every form of the disease and does not completely replace surgery in every case, it has become an important first-line diagnostic tool supported by current international guidelines.³

For many people living with chronic pelvic pain or other symptoms of endometriosis, access to expert imaging may mean receiving answers sooner, reducing unnecessary delays, and helping guide more personalized treatment decisions.

References (AMA)

1. Zondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl J Med. 2020;382(13):1244-1256. doi:10.1056/NEJMra1810764
2. Taylor HS, Kotlyar AM, Flores VA. Endometriosis is a chronic systemic disease: clinical challenges and novel innovations. Lancet. 2021;397(10276):839-852. doi:10.1016/S0140-6736(21)00389-5
3. Becker CM, Bokor A, Heikinheimo O, et al. ESHRE guideline: endometriosis. Hum Reprod Open. 2022;2022(2):hoac009. Updated recommendations remain current through the 2025 ESHRE guideline update. doi:10.1093/hropen/hoac009
4. Guerriero S, Condous G, van den Bosch T, et al. Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including the IDEA consensus. Ultrasound Obstet Gynecol. 2016;48(3):318-332. doi:10.1002/uog.15955
5. Nisenblat V, Bossuyt PM, Farquhar C, et al. Imaging modalities for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev. 2016;2:CD009591. Updated evidence continues to support expert TVUS as the preferred first-line imaging modality for deep endometriosis. doi:10.1002/14651858.CD009591.pub2