Aim
The aim of this clinical practice point is to highlight the role of less invasive diagnostic methods to health professionals caring for people with symptoms suggestive of endometriosis, such as ultrasound and magnetic resonance imaging (MRI), for the diagnosis of endometriosis. More invasive methods such as diagnostic laparoscopy are not required as an initial diagnostic tool unless there are specific circumstances where this is warranted.
Background
In 2025 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), developed the Australian Living Evidence Guideline: Endometriosis; a clinical resource which provides the best available scientific evidence to assist the diagnosis and management of endometriosis and a related condition, adenomyosis. The living guideline presents the most up to date evidence for first line diagnosis of endometriosis using non-invasive techniques. A quick reference guide and flowchart have been designed specifically to support primary care providers, and there are also resources available for the public.
Endometriosis
Endometriosis is a chronic, inflammatory, gynaecologic condition characterised by the presence of endometrial-like tissue outside the uterus.
1 in 7 (14%) people assigned female at birth in Australia between 18 and 45 are diagnosed with endometriosis by age 44–49.
Symptoms associated with endometriosis vary, with some people experiencing very few or no symptoms, while others may have significant and recurring symptoms that substantially affect their quality of life.
The most common symptoms associated with endometriosis include pelvic pain, pain with periods, pain with sex, heavy menstrual bleeding or sub-fertility.
A holistic approach to care must include validation of symptoms and recognition of the broader impact that chronic pelvic pain has on a person’s life.
Delays in treating endometriosis may have been influenced by waiting for surgical confirmation, and by misconceptions that significant period pain is typical or normal. It is essential to take symptoms seriously and avoid normalising ongoing pelvic pain. These delays can prolong suffering and postpone appropriate treatment.
Current practice emphasises early assessment and management. For some people a diagnosis of endometriosis as a possible contributor to their symptoms may be important while for others not. Treatment should not be delayed in individuals with persistent or chronic pelvic pain while investigations are being arranged.
The use of less invasive methods of investigation, such as transvaginal ultrasound, is now recommended as the first step in the diagnosis of endometriosis. When performed and reported by appropriately trained specialists, transvaginal ultrasound can accurately identify endometriomas and deep infiltrating disease, allowing many individuals to receive a working diagnosis and begin management without requiring surgery.
If ultrasound is not appropriate, an MRI can be useful. However, advanced imaging for endometriosis is highly specialised. Access to clinicians with this expertise may be limited, and even high-quality imaging can occasionally miss clinically significant disease. Patients should be supported to access specialist imaging where appropriate, while also being informed of its limitations.
If transvaginal ultrasound or MRI do not show evidence of endometriosis, then a laparoscopy can be considered to diagnose or exclude endometriosis and should only be undertaken as a shared decision between patient and doctor.
Implications for clinical practice
- Pelvic examination can be offered as part of an initial assessment, although there is very limited evidence that clinical examination can diagnose endometriosis, it may help to rule out other causes of symptoms. Pelvic examination may not be appropriate for some people, and normal clinical examination does not rule out endometriosis
- People with suspected endometriosis should be offered transvaginal ultrasound as the preferred method of first line diagnostic investigation, although it may not always be possible or appropriate.
- Pelvic MRI can be offered where pelvic ultrasound is not appropriate, or where deep endometriosis is suspected based on examination or transvaginal ultrasound.
- Pelvic MRI is important for those people where transvaginal ultrasound is not appropriate. It is a limited resource, but it can be assessed and reported by a specialist via telehealth
- Transabdominal ultrasound can be offered when transvaginal ultrasound and pelvic MRI are not available or appropriate
- Investigations such as ultrasound and pelvic MRI performed and interpreted by a healthcare professional with specialist expertise in endometriosis are likely to have higher diagnostic accuracy for endometriosis.
- Specialist providers can diagnose deep endometriosis in addition to endometrioma. General Providers can accurately detect endometrioma(s) and may rule out other contributors of pelvic pain, such as fibroids and adenomyosis. It is appropriate as a first line investigation if specialist imaging providers are not available.
- A transvaginal ultrasound or MRI assessment that has been done by a specialist and reported as normal may not detect endometriosis in people with superficial, and sometimes moderate endometriosis, and for this reason diagnosis and management with laparoscopy may be appropriate when discussed and agreed with people as part of the shared decision making process.
- Evidence shows enhanced recovery for patients with pelvic pain who are treated in a holistic manner, taking into account biopsychosocial factors, and supporting their active participation in care.
References
Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) (2025) Australian Living Evidence Guideline: Endometriosis, Melbourne: RANZCOG. Available at: https://ranzcog.edu.au/wp-content/uploads/Endometriosis-Clinical-Practice-Guideline.pdf (Accessed: 23 March 2026).
This Practice Point was written in partnership with Safer Care Victoria, the Victorian Perioperative Consultative Council (VPCC) and Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG).