The British Journal of Radiology, 74 (2001), 556–562
Pictorial review
Imaging features of pelvic endometriosis
N UMARIA, FRCR and J F OLLIFF, FRCR
Department of Clinical Radiology, Queen Elizabeth Hospital, Birmingham B15 2TH, UK
Abstract. Although laparoscopy remains the investigation of choice in the diagnosis of
endometriosis, imaging does play a significant role in its management. This pictorial review
concentrates on the techniques used in the imaging of endometriosis.
Endometriosis is characterized by the presence
of ectopic endometrial tissue outside the uterus.
Originally described by Von Rokitansky in 1860
[1], endometriosis occurs in up to 10% of women
and is found almost exclusively in women of
reproductive age. The exact pathogenesis is
unclear but theories include: (1) metaplastic
transformation of peritoneal epithelium into
functional endometrium; (2) peritoneal seeding
by way of retrograde menstruation; and (3)
endometrium in the peritoneal cavity from retro-
grade flow activates differentiation of mesenchy-
mal cells (induction theory) [2].
The commonest sites for endometrial implanta-
tion within the pelvis are the ovaries, broad and
round ligaments, Fallopian tubes, cervix, vagina
and pouch of Douglas. The gastrointestinal tract
may be involved in about 12% of cases and the
urinary tract is affected in about 1%. Symptoms
include pelvic pain, dysmenorrhoea and dyspar-
unia. 30–40% of patients suffer with infertility [3].
The hallmarks of endometriosis are endome-
triomas (multiloculated cystic lesions), peritoneal
implants (solid endometrial tissue) and adhesions.
Diagnosis
Laparoscopy
Laparoscopy is the gold standard for the
diagnosis of endometriosis when black or
brown/blue nodules, resulting from repeated
haemorrhage and retention of haemosiderin, are
seen on the peritoneal surfaces of structures
around the uterus.
Serum markers
Currently available laboratory tests lack the
necessary sensitivity and specificity to serve as
Received 29 March 2000 and in revised form 8 August
2000, accepted 31 August 2000.
Address correspondence to Dr J F Olliff.
556
E 2001 The British Institute of Radiology
reliable screening tests for endometriosis,
although there is growing evidence that carcino-
embryonic antigen CA125 may help to evaluate
selected populations at risk, to follow the course
of the disease and to monitor response to
treatment [4].
Imaging studies
Ultrasound
High resolution images may be obtained via the
transvaginal approach using a 7.5 mHz probe.
Sensitivity in the detection of focal endometrial
implants is poor. However, the detection of
endometriomas using ultrasound is excellent,
with reports of 83% sensitivity and 98% specifi-
city. Diagnostic accuracy may be enhanced by
Doppler flow studies where blood flow in endo-
metriomas is usually pericystic with a resistive
index above 0.45 [4].
There is a broad range of ultrasound appear-
ances of endometriomas. Diffuse, low level
internal echoes occur in 95% of endometriomas
(Figure 1). Hyperechoic wall foci and multilocu-
larity also point towards an endometrioma [5].
CT
Endometriomas may appear solid, cystic, or
mixed solid and cystic, resulting in an overlap in
the appearances with an abscess, ovarian cyst or
even a malignant lesion (Figure 2). Owing to the
poor specificity and high radiation dose, use of
CT in the evaluation of pelvic endometriosis has
been replaced by MRI.
MRI
Identification of endometriomas by MRI relies
on detection of pigmented haemorrhagic lesions.
Signal characteristics vary according to the age of
haemorrhage. (a) Typically, lesions appear hyper-
intense on T1 weighted spin echo (T1WSE) images
and hypointense (shading) on T2 weighted turbo
spin echo (T2WTSE) images owing to the pres-
ence of deoxyhaemoglobin and methaemoglobin
The British Journal of Radiology, June 2001
Pictorial review: Imaging of endometriosis
(Figure 3). (b) Acute haemorrhage occasionally
appears hypointense on T1WSE and T2WTSE
sequences. (c) Old haemorrhage occasionally
appears hyperintense on T1WSE and T2WTSE
images [4].
Multiple hyperintense lesions on T1WSE
sequences, irrespective of the intensity on
T2WTSE sequences, are characteristic of endo-
metriosis. Sensitivities and specificities of 90% and
98%, respectively, have been achieved using
standard T1WSE and T2WTSE sequences [6].
Endometrial implants are often small and
express signal intensity similar to that of normal
endometrium on both T1WSE and T2WTSE
images [7]. Depending on hormonal influences,
they exhibit varying degrees of haemorrhage.
MRI has poor sensitivity (27%) [8] in the
detection of implants using T1WSE and T2WTSE
sequences. Identification of small implants is
better achieved with T1WSE fat suppressed
images, increasing the sensitivity to 61% [8]
(Figure 4).
Contrast enhanced fat saturated sequences
occasionally demonstrate diffuse peritoneal
enhancement secondary to tiny implants, particu-
larly in the region of the uterine ligaments and
within the cul-de-sacs [3].
Adhesions are diagnosed when a clear interface
between an endometrioma and adjacent organs
cannot be demonstrated, although this may be
difficult to recognize on MRI.
Sites of disease
Ovary
The ovaries are the commonest site of endo-
metrial involvement and may be affected in two
ways: (a) small endometrial implants may cause
paraovarian scarring and adhesions; and (b) the
ovary enlarges with repeated haemorrhage and
evolves into a chocolate cyst.
The ovary may contain multiple loculi with
fluid–fluid levels, consistent with products of
repeated haemorrhage, or lesions may display
homogeneous high signal on T1WSE images with
multiple low signal internal linear septations.
Uterine ligaments and Fallopian tubes
Involvement of the uterine ligaments produces
thickening and nodularity, which is usually
palpable on physical examination. Contrast
enhancement may occur due to a secondary
inflammatory reaction (Figure 5).
The British Journal of Radiology, June 2001
Endometriosis of the Fallopian tubes usually
occurs in the subserosal layer and displays
hyperintense foci on T2WTSE and post-contrast
T1WSE sequences.
Detection of parametrial disease is often
difficult with MRI owing to the surrounding
vascular structures, although any asymmetry of
signal intensity raises the suspicion of disease.
Uterus and cervix
The uterus may be affected in two ways: (a)
serosal surface nodules (Figure 6), which may be
manifested on contrast enhanced fat saturated
MR images as diffuse peritoneal enhancement;
and (b) adenomyosis, where there is invasion of
the endometrium into the myometrium. Diffuse
or focal widening of the junctional zone more
than 5 mm in thickness confirms the diagnosis of
adenomyosis. This is best seen on T2WTSE
images as diffuse low intensity areas, which may
be accompanied by tiny high intensity foci [9]
(Figure 7).
Cul-de-sac
Endometriosis in the cul-de-sacs and recto-
vaginal septum may occur as tiny high signal foci on
T1WSE weighted images (Figures 8 and 9). Thick
adhesions and partial obliteration of the cul-de-
sacs by scar tissue occasionally occurs with loss of
the distinct interface between the structures. The
presence of simple fluid here is not associated with
endometriosis.
Other sites of endometriosis
Endometriosis of the alimentary tract usually
affects the rectosigmoid colon. Unlike neoplastic
lesions, the mucosa is not affected. Contrast
enema examination may show a constricting or an
eccentric intramural filling defect [3] (Figure 10).
The ileum and appendix may also be affected.
The urinary tract may also be involved, with
the bladder being affected in 84% of cases.
Endometrial implants on the posterior wall and
the dome of the bladder produce filling defects
seen on intravenous urography and display
multiple high signal foci on T1WSE and
T2WTSE MRI (Figure 11). Ureteral involvement
is less frequent, but extrinsic compression can
produce obstruction.
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 N Umaria and J F Olliff

Figure 1. Transabdominal ultrasound showing a multi-

loculated right ovarian endometrioma containing low
level echoes.

Figure 2. Oral and intravenous contrast enhanced CT

through the pelvis showing partly solid, partly cystic
mass posterior to the uterus and anterior to the recto-
sigmoid junction (arrowheads). This was an endome-
trioma.

(a) (b)

Figure 3. Multiloculated left ovarian endometrioma showing (a) high signal intensity on T1 weighted spin echo
axial image and (b) low signal intensity on T2 weighted turbo spin echo image (arrowheads), in keeping with the
products of haemorrhage.

558 The British Journal of Radiology, June 2001

Pictorial review: Imaging of endometriosis

(a) (b)

Figure 4. The left pelvic endometrioma (arrow) is barely perceptible on the standard T1 weighted spin echo
(T1WSE) axial image (a), but is much better appreciated as an area of high signal intensity on the T1WSE fat
suppressed sequence (b) owing to the presence of methaemoglobin.

(a) (b)

Figure 5. Endometriosis of the round ligament. (a) T1 weighted spin echo (T1WSE) fat suppressed and (b) post-
contrast T1WSE fat suppressed sequence showing enhancement of both round ligaments (arrows) owing to
inflammation secondary to endometriosis. Note the two large endometriomas containing the products of haemor-
rhage anterior to the uterus and posterior to the right round ligament (arrowheads).

The British Journal of Radiology, June 2001 559

 N Umaria and J F Olliff

(a) (b)

Figure 6. Endometriosis of the serosal surface of the uterus. T1 weighted spin echo (T1WSE) (a) and T2 weighted
turbo spin echo (T2WTSE) (b) sagittal images of the uterus showing mixed high and low signal foci on the pos-
terior superior surface of the uterus (arrowheads) on T1WSE, which are of high signal intensity on T2WTSE.

(a) (b)

Figure 7. Endometriosis of the uterus. (a) T2 weighted turbo spin echo (T2WTSE) sagittal image of the uterus
showing diffuse thickening of the junctional zone (low signal intensity area) with multiple areas of high and low
signal intensity in the myometrium (arrows), which remained high signal on T1 weighted spin echo (T1WSE)
sequences (not shown here). Areas of mainly high signal intensity on the posterior lip of the cervix on T2WTSE
as well as intermediate signal intensity on the axial T1WSE (b) sequences may represent either a further area of
endometriosis or a Nabothian cyst.

560 The British Journal of Radiology, June 2001

Pictorial review: Imaging of endometriosis
Figure 8. Endometriosis of the rectovaginal septum.
T2 weighted turbo spin echo sagittal image showing
high signal intensity in the region of the rectovaginal
septum (arrow), which was also of high signal on T1
weighted spin echo images (not shown here).
(a)
(b)
Figure 9. Endometriosis in the pouch of Douglas.
High signal intensity foci on (a) T1 weighted spin
echo and (b) T2 weighted turbo spin echo sagittal
sequences owing to extracellular methaemoglobin
(arrows).
The British Journal of Radiology, June 2001
(a)
(b)
(c)
Figure 10. Endometriosis of the bowel. (a) Double
contrast barium enema examination showing extrinsic
compression and puckering of the serosa (arrows) in
the region of the rectosigmoid junction. (b) T1
weighted spin echo (T1WSE) and (c) T2 weighted
turbo spin echo (T2WTSE) axial images through the
pelvis of the same patient showing a left-sided multi-
loculated endometrioma (arrowheads) displaying high
signal intensity and low signal intensity shading cen-
trally on T1WSE and T2WTSE images, respectively.
There are also multiple cysts in the right ovary.
561
 N Umaria and J F Olliff

Conclusion
Laparoscopy still remains the procedure of
choice in the initial diagnosis of the disease, as the
sole use of imaging is not sensitive or specific
enough in the diagnosis of endometriosis.
Ultrasound as an initial investigation may point
towards pathology in the pelvis. However, MRI is
now more frequently used, particularly in staging
and monitoring response to treatment.

Acknowledgments
The authors would like to thank Dr Peter
Guest from the Department of Radiology, Queen
Elizabeth Hospital, Birmingham for kindly pro-
viding some of the images.

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562 The British Journal of Radiology, June 2001