Imaging modalities for the non-invasive diagnosis of endometriosis
Open accessAbstract
BACKGROUND: About 10% of women of reproductive age suffer from endometriosis. Endometriosis is a costly chronic disease that causes pelvic pain and subfertility. Laparoscopy, the gold standard diagnostic test for endometriosis, is expensive and carries surgical risks. Currently, no non-invasive tests that can be used to accurately diagnose endometriosis are available in clinical practice. This is the first review of diagnostic test accuracy of imaging tests for endometriosis that uses Cochrane methods to provide an update on the rapidly expanding literature in this field. OBJECTIVES: • To provide estimates of the diagnostic accuracy of imaging modalities for the diagnosis of pelvic endometriosis, ovarian endometriosis and deeply infiltrating endometriosis (DIE) versus surgical diagnosis as a reference standard.• To describe performance of imaging tests for mapping of deep endometriotic lesions in the pelvis at specific anatomical sites.Imaging tests were evaluated as replacement tests for diagnostic surgery and as triage tests that would assist decision making regarding diagnostic surgery for endometriosis. SEARCH METHODS: We searched the following databases to 20 April 2015: MEDLINE, CENTRAL, EMBASE, CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, MEDION, DARE, and PubMed. Searches were not restricted to a particular study design or language nor to specific publication dates. The search strategy incorporated words in the title, abstracts, text words across the record and medical subject headings (MeSH). SELECTION CRITERIA: We considered published peer-reviewed cross-sectional studies and randomised controlled trials of any size that included prospectively recruited women of reproductive age suspected of having one or more of the following target conditions: endometrioma, pelvic endometriosis, DIE or endometriotic lesions at specific intrapelvic anatomical locations. We included studies that compared the diagnostic test accuracy of one or more imaging modalities versus findings of surgical visualisation of endometriotic lesions. DATA COLLECTION AND ANALYSIS: Two review authors independently collected and performed a quality assessment of data from each study. For each imaging test, data were classified as positive or negative for surgical detection of endometriosis, and sensitivity and specificity estimates were calculated. If two or more tests were evaluated in the same cohort, each was considered as a separate data set. We used the bivariate model to obtain pooled estimates of sensitivity and specificity when sufficient data sets were available. Predetermined criteria for a clinically useful imaging test to replace diagnostic surgery included sensitivity ≥ 94% and specificity ≥ 79%. Criteria for triage tests were set at sensitivity ≥ 95% and specificity ≥ 50%, ruling out the diagnosis with a negative result (SnNout test - if sensitivity is high, a negative test rules out pathology) or at sensitivity ≥ 50% with specificity ≥ 95%, ruling in the diagnosis with a positive result (SpPin test - if specificity is high, a positive test rules in pathology). MAIN RESULTS: We included 49 studies involving 4807 women: 13 studies evaluated pelvic endometriosis, 10 endometriomas and 15 DIE, and 33 studies addressed endometriosis at specific anatomical sites. Most studies were of poor methodological quality. The most studied modalities were transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI), with outcome measures commonly demonstrating diversity in diagnostic estimates; however, sources of heterogeneity could not be reliably determined. No imaging test met the criteria for a replacement or triage test for detecting pelvic endometriosis, albeit TVUS approached the criteria for a SpPin triage test. For endometrioma, TVUS (eight studies, 765 participants; sensitivity 0.93 (95% confidence interval (CI) 0.87, 0.99), specificity 0.96 (95% CI 0.92, 0.99)) qualified as a SpPin triage test and approached the criteria for a replacement and SnNout triage test, whereas MRI (three studies, 179 participants; sensitivity 0.95 (95% CI 0.90, 1.00), specificity 0.91 (95% CI 0.86, 0.97)) met the criteria for a replacement and SnNout triage test and approached the criteria for a SpPin test. For DIE, TVUS (nine studies, 12 data sets, 934 participants; sensitivity 0.79 (95% CI 0.69, 0.89) and specificity 0.94 (95% CI 0.88, 1.00)) approached the criteria for a SpPin triage test, and MRI (six studies, seven data sets, 266 participants; sensitivity 0.94 (95% CI 0.90, 0.97), specificity 0.77 (95% CI 0.44, 1.00)) approached the criteria for a replacement and SnNout triage test. Other imaging tests assessed in small individual studies could not be statistically evaluated.TVUS met the criteria for a SpPin triage test in mapping DIE to uterosacral ligaments, rectovaginal septum, vaginal wall, pouch of Douglas (POD) and rectosigmoid. MRI met the criteria for a SpPin triage test for POD and vaginal and rec
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Patients may be given an endometriosis diagnosis following clinical assessment, imaging, or surgery.
“Patients may be given a diagnosis following clinical assessment (Agarwal et al., 2019), imaging (Nisenblat et al., 2016) or surgery (Wykes et al., 2004).”
From Self-management strategies to consider to combat endometriosis symptoms during the COVID-19 pandemic (2020) · cites this paper as Nisenblat et al., 2016
The Authors’ conclusions say imaging can help identify particular forms of endometriosis: transvaginal ultrasound may aid assessment of endometrioma, and MRI showed potential as a replacement test for it, though evidence was scant. They also say no evaluated imaging modality was accurate enough to replace surgery for diagnosing overall pelvic endometriosis. The citation therefore supports diagnosis following imaging only in a narrower, qualified sense. (LLM, conf=0.87)
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- Authors
- Nisenblat, V., Bossuyt, P. M., Farquhar, C., Johnson, N., & Hull, M. L.
- Affiliations
- The University of Adelaide (AU)
- Amsterdam UMC Location University of Amsterdam (NL)
- University of Auckland (NZ)
- Venue
- Cochrane Database of Systematic Reviews
- Publisher
- Wiley
- Published
- 2016-02-26
- Volume
- 2016
- Issue
- 2
- Pages
- CD009591-CD009591
- ISSN
- 1361-6137 (ISSN-L)
- 1465-1858
- PMC
- PMC7100540
- OpenAlex
- W2291336593
- Cited by
- 538
- References
- 11
- Citations by year
- 2026: 32 · 2025: 50 · 2024: 73 · 2023: 66 · 2022: 76 · 2021: 63 · 2020: 59 · 2019: 48 · 2018: 31 · 2017: 27 · 2016: 10
- FWCI
- 5.57
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Cochrane Database of Systematic Reviews (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Pure Amsterdam UMC (submittedVersion)
- Topics
- Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
- Health Sciences › Medicine › Obstetrics and Gynecology › Gynecological conditions and treatments
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ectopic Pregnancy Diagnosis and Management
- Keywords
- endometriosis, pelvic endometriosis, endometrioma, deep infiltrating endometriosis, diagnostic imaging, diagnostic accuracy, non-invasive diagnosis, sensitivity and specificity, diagnostic triage, surgical diagnosis, pelvic pain, subfertility, bivariate models
- MeSH terms
- Chronic Disease, Cross-Sectional Studies, Diagnostic Imaging, Endometriosis, Female, Humans, Magnetic Resonance Imaging, Ovarian Diseases, Pelvis, Sensitivity and Specificity, Ultrasonography, Randomized Controlled Trials as Topic, Positron-Emission Tomography
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