Testing for endometriosis involves several steps, starting with a clinical evaluation and often followed by imaging studies. However, a definitive diagnosis typically requires a surgical procedure called laparoscopy.
Endometriosis is a chronic condition where tissue similar to the lining of the uterus (called endometrial stroma and glands) grows in places outside the womb. This can cause pain, inflammation, and complications with fertility.
How Common Is Endometriosis?
Endometriosis affects an estimated 10% of women and individuals assigned female at birth during their reproductive years. This equates to around 190 million people worldwide [1].
Despite its prevalence, many individuals remain undiagnosed. The average delay from symptom onset to diagnosis is around 7–10 years [2].
Testing early and accurately is essential to limit complications and improve quality of life.
Where Does Endometriosis Occur in the Body?
Endometrial-like tissue can attach to several anatomical sites:
- Ovaries (can develop into endometriomas, or “chocolate cysts”)
- Fallopian tubes
- Uterine ligaments and outer surface of the uterus
- Pelvic peritoneum (lining of the abdominal cavity)
- Bowel, bladder, and ureters
- Rectovaginal septum (tissue between the rectum and vagina)
In rare cases, it can occur in the lungs, diaphragm, or surgical scars. These abnormal implants bleed and swell in response to hormonal changes, causing pain and inflammation.
Symptoms That Prompt Testing
Testing is usually initiated due to persistent symptoms such as:
- Pelvic pain, especially during menstruation
- Painful intercourse (dyspareunia)
- Pain with bowel movements or urination, especially during periods
- Heavy or irregular menstrual bleeding
- Chronic fatigue
- Infertility or difficulty conceiving
Symptoms may vary in intensity and are not always related to the stage of disease. Some individuals may have no symptoms at all.
Step-by-Step Testing Process
1. Clinical History and Symptom Review
A thorough medical history is the starting point. A doctor will ask about:
- Menstrual cycle patterns
- Nature and severity of pain
- Gastrointestinal or urinary symptoms
- Family history of endometriosis
- Fertility challenges
A detailed symptom diary can be helpful for tracking pain patterns and triggers.
2. Physical Examination
A pelvic exam may be performed to check for:
- Tenderness
- Masses (such as ovarian cysts)
- Nodules or scarring in the pelvic cavity
However, this exam may be normal in early or mild cases. Many lesions are too small or deep to be detected manually.
3. Imaging Tests
Imaging helps identify signs of endometriosis, although it cannot detect all types.
Transvaginal ultrasound (TVUS):
- A probe is inserted into the vagina to visualise pelvic organs.
- Particularly useful for detecting ovarian cysts (endometriomas).
Pelvic ultrasound:
- Performed externally through the abdomen.
- Less detailed than TVUS but helpful in initial assessments.
MRI (Magnetic Resonance Imaging):
- Provides detailed images of soft tissues.
- Useful for mapping deep infiltrating endometriosis (lesions that grow into pelvic structures).
Imaging is valuable but not definitive. Small or superficial lesions often go undetected.
4. Laparoscopy – Confirmatory Test
Laparoscopy is a minimally invasive surgical procedure that remains the gold standard for diagnosis.
- A small incision is made near the belly button.
- A thin camera (laparoscope) is inserted to view the pelvic organs directly.
- Suspicious lesions can be removed or biopsied for histological confirmation (microscopic tissue analysis).
This is the only way to confirm endometriosis with certainty.
It also allows simultaneous treatment, such as removing or destroying endometrial growths.
Disease Classification
During laparoscopy, endometriosis is staged using the revised American Society for Reproductive Medicine (rASRM) system:
- Stage I (Minimal): Few, superficial lesions
- Stage II (Mild): More lesions, some deeper involvement
- Stage III (Moderate): Deep lesions with small ovarian cysts
- Stage IV (Severe): Extensive disease, large cysts, and dense adhesions (scar tissue)
The stage does not always reflect symptom severity. Some individuals with minimal disease may have severe pain, and vice versa.
Misconceptions About Testing
Myth: A normal scan rules out endometriosis
Fact: Many lesions are invisible on imaging. A normal scan does not exclude the condition.
Myth: Painful periods are normal
Fact: While some discomfort is expected, pain that affects daily life is not normal and should be investigated.
Myth: Only older women are affected
Fact: Endometriosis can begin in adolescence, and early signs should not be ignored.
Complications If Undiagnosed
Untreated endometriosis can lead to:
- Infertility (affecting up to 50% of cases [3])
- Chronic pelvic pain
- Adhesions that distort pelvic organs
- Bowel or urinary dysfunction
- Psychological effects, including anxiety and depression
Early testing reduces the risk of complications and supports better outcomes.
When to Seek Medical Advice
Speak to a healthcare provider if you:
- Have painful or heavy periods that interfere with your routine
- Experience persistent pelvic pain
- Have pain during sex, bowel movements, or urination
- Have trouble becoming pregnant
Keeping a symptom diary and advocating for further tests can support timely diagnosis.
Conclusion
Testing for endometriosis involves clinical assessment, imaging, and potentially surgery. While scans and exams can raise suspicion, only laparoscopy can confirm the diagnosis.
Early testing is important to manage symptoms, reduce complications, and protect fertility. If you suspect endometriosis, consult a doctor and request further investigation.
References
[1] Giudice, L.C. Endometriosis: Science and Practice
[2] Vercellini, P., et al. Clinical Management of Endometriosis
[3] Rizk, B., et al. Endometriosis and Infertility: A Comprehensive Guide
