Optimizing endometriosis detection: a review of technical approaches and interpretative pitfalls

Endometriosis, affecting approximately 10% of reproductive-age women, presents significant diagnostic challenges due to its variable clinical presentation and anatomic distributions. Despite advances in imaging technology, accurate detection and characterization of endometriotic lesions remain complex, with diagnostic delays averaging 7-12 years from symptom onset. This review analyzes the spectrum of imaging strengths and potential pitfalls across imaging modalities used to assess endometriosis focusing on technical factors and anatomic blind spots that can impact diagnostic accuracy and clinical management. Strengths of ultrasound include dynamic capabilities and real-time assessment with patient feedback, though it requires experienced operators and standardized protocols. MRI offers comprehensive evaluation with excellent soft tissue contrast and multiplanar capabilities but faces challenges with static imaging and artifact interference. CT, while limited by radiation exposure and intermediate contrast resolution, shows promise in specific scenarios, particularly evaluation of endometriosis deposits on the bowel. This review details optimal patient preparation strategies, including the role of vaginal and rectal gel opacification, bowel preparation, and contrast administration. Special attention is given to challenging anatomic areas including thoracic, gastrointestinal, abdominal wall, urinary tract and neurovascular involvement. The manuscript emphasizes the importance of standardized reporting templates for communication of findings to facilitate surgical planning. A multidisciplinary approach to imaging patients with known deep invasive endometriosis helps ensure the best modality is chosen for the clinical question at hand.