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Endometriosis is a long-term, recurrent, debilitating challenge to therapy and affects 5-10% of women.

It is characterized by the presence of endometrial glands and stroma outside the endometrial cavity-on the pelvic peritoneum, ovaries, and the recto-cervical septum.

The prevalence of endometriosis in normal women is 2-10% while it occurs in 20-50% of women with infertility. It is prevalent in over 60% of women with chronic pelvic pain and dysmenorrhea.

The maximum incidence is between 25-30 years.

Clinical features of endometriosis

The GDG (Guidelines Development Group) recommends considering the diagnosis of endometriosis with anyone of the following:

1. Gynecological symptoms-Dysmenorrhea, Chronic pelvic pain, deep dyspareunia, infertility, fatigue
2. Non-gynecological symptoms-Dyschezia, dysuria, hematuria, shoulder pain and rectal bleeding.

Diagnosis of endometriosis

1. Clinical examination - Most times it may appear to be normal. However, a prevaginal or per-rectal examination can give a clue about it. Painful induration and/or recto-vaginal wall nodules felt or seen in the posterior vaginal fornix may be features of deep endometriosis. An adnexal mass of an endometrioma can also be present.
2. Transvaginal Scan.
   1. Endometriotic nodules are not visible on a TVS. However, an endometrioma can be detected. A typical endometrioma appears like an oval mass, with hypoechoic contents and a hyperechoic wall and no papillae within. An endometrioma can also show atypical features like septae, papillae, non-homogenous content with irregular internal wall.
   2. Doppler Ultrasound - Hilus sign - presence of vessels between the cyst capsule and ovarian parenchyma is a feature of endometrioma.
   3. The differential diagnosis of an endometrioma includes a cystadenoma, dermoid cyst, hemorrhagic cyst, luteinized unruptured follicle and a corpus luteal cyst.
   4. 3D ultrasound for diagnosis of rectovaginal endometriosis is not a well-established tool yet.

The following table guides the diagnosis of endometrioma:

	Endometrioma	Corpus luteum	Cystadenoma	Dermoid
Septae	Infrequent	No	Frequent	Infrequent
Inhomogeneous content	Infrequent	Frequent	Rare	Frequent
Posterior reinforcement	No	No	No	Frequent
Hypoechogenic dots	Frequent	No	No	No

3. MRI- Useful in the diagnosis of extraovarian endometriosis

4. CA-125 or other biomarkers in endometrial tissue, follicles, menstrual blood must not be used for diagnosis of endometriosis.

5. Laparoscopy with HPE of the tissue was considered as gold-standard for diagnosis. However, ESHRE 2022 guidelines do not consider it as the diagnostic gold standard any longer. Laparoscopy has been recommended only in the event of a negative imaging and/or when empirical therapy was unsuccessful or inappropriate.

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