The Seckin Endometriosis Center is determined to be here for you during the COVID-19 Pandemic and Beyond. We are now offering Telemedicine Consultations.

Diagnosing Endometriosis

by Tamer Seckin, MD | Posted on June 10, 2020


Endometriosis is often one of the most underdiagnosed, misdiagnosed, and mistreated diseases in reproductive-aged women. Because the first step to receiving successful treatment is a proper diagnosis, it is imperative to find an endometriosis surgeon who will use and review all diagnostic tools to his or her disposal. This includes imaging techniques such as sonography, MRI, and laparoscopy. However, another crucial diagnostic tool that often goes underappreciated is a physical exam, which entails the patient providing a thorough overview of their symptoms and past medical history. It is important to find a surgeon who will listen to these symptoms as painful periods, painful sex (dyspareunia), gastrointestinal distress (which can often be seen in young age women in the form of constipation), painful bowel movements, and diarrhea can be highly suggestive indicators for a presumptive endometriosis diagnosis. It is key to find a surgeon who is not only knowledgeable, but also compassionate and patient enough to listen to your full story, as these elements can help to make up a highly accurate, but still speculative, diagnosis.

What are the steps to diagnosing endometriosis?

Diagnosing endometriosis requires three levels of diagnostic evaluation:

  • Step 1 (pre-surgery): The initial stage is a clinical examination and appropriate testing, which includes a pelvic examination and ultrasound. During this time, patients thoroughly recount their current symptoms, as their doctor intently listens in order to build trust necessary to facilitate long time care. Upon physical examination, such findings as the cervix, pelvic side, and posterior thigh tenderness, which can radiate as far back to the cervix at the rectal wall, serve as key telling signs of endometriosis lesions and their possible locations. Sonogram technology can help confirm the cause of this tenderness. If you have diffuse pelvic tenderness, a rectal exam may also be conducted as it is important to determine if there is localized rectovaginal tenderness, a key sign of rectovaginal disease.
  • Step 2 (during surgery): The second stage is visual diagnosis by recognition of endometriotic lesions through laparoscopy. This will be performed in the operating room, during laparoscopic surgery.
  • endometriosis scar tissue must be excised, collected and sent off to a pathology lab
    In order for endometriosis to be confirmed, believed endometriosis scar tissue must be excised, collected and sent off to a pathology lab.
    Step 3 (after surgery): The final formal diagnosis of endometriosis cannot be made without the pathologic examination of lesions under a microscope. Surgical specimens obtained through laparoscopic deep excision surgery must be sent off to the lab. It usually takes a few days following your surgery to assess those specimens.

What testing is performed pre-surgery?

  • Pelvic Exam: This physical examination of a patient’s pelvis and pelvic organs is part of any fully comprehensive gynecological exam. During this exam, a physician will look for any and all points of pelvic tenderness. Through a pelvic exam, your doctor will be able to gain a better understanding of your symptoms and any pain you may be experiencing. If your physician specializes in endometriosis, they may even be able to diagnose such conditions as frozen pelvis.
  • Transvaginal Ultrasound: An ultrasound is a safe and painless technique that uses sound waves to produce detailed images of inside the body. A small probe, called a transducer, is inserted into your vagina similar to the way you would insert a tampon. Sound waves will then pass harmlessly through the skin from the transducer, bouncing off certain organs and tissue in the body and creating "echoes." The echoes are reflected back to the transducer, which converts the echoes to electrical signals in order to produce an image. The images are viewed in real-time on a monitor and are also recorded and photographed for your physician to review. It is important to note that this test can be performed during menstruation.
    An image of the uterus using ultrasound technology
    An image of the uterus using ultrasound technology.
  • Sonohysterography: During this imaging technique, fluid is injected through the cervix into the uterus. Ultrasound is then used to produce images of the uterine cavity, and the use of this fluid provides more detail of the inside of the uterus than if an ultrasound was performed alone. This procedure is performed to find the underlying causes of abnormal uterine bleeding, miscarriage, and infertility, as it can detect:
    1. Abnormal uterine growths (i.e. fibroids or polyps)
    2. Uterine scarring
    3. Abnormal uterine shape
    This procedure cannot be scheduled during your menstrual cycle or when you are experiencing abnormal bleeding. In cases of abnormal bleeding, the test can be performed as soon as the bleeding stops. After this exam, you may have some cramping, spotting, and watery discharge. The procedure is generally safe, but in rare cases, there is a risk of pelvic infection.
  • MRI depicting endometriosis
    MRI depicting endometriosis.
    MRI: Magnetic resonance imaging (MRI) is a noninvasive imaging device that produces strong magnetic field and radio waves that are used to create detailed images of the tissues, organs, and other areas. An MRI differs from a CT scan as it uses low-frequency magnetic fields as opposed to the high energy X-rays that a CT scan uses, which often put patients at a risk for radiation exposure. An MRI produces much more comprehensive and detailed imaging than an ultrasound, as it often encompasses the entire body. Unfortunately, an MRI is much more expensive than an ultrasound. MRI testing is also not conducted in the office of your everyday primary care physician or gynecologist, but rather done upon referral. Nevertheless, MRI testing serve as a very useful tool for your doctor in obtaining an idea of the extent of your endometriosis. As a result, it is very common for your specialist to ask for an MRI test to be conducted prior to surgical treatment for endometriosis.

What testing is performed during surgery?

  • hysteroscopy, An imaging technique performed in the operating room in order to view the lining of the uterus (endometrium)
    Hysteroscopy: An imaging technique performed in the operating room in order to view the lining of the uterus (endometrium). This is done using a thin tool with a light and camera (the hysteroscope) attached to its tip, which is gently inserted into the vagina, through the cervix, and into the uterus. With this technique, a surgeon will be able to see if there is any uterine cause for heavy menstrual bleeding, pelvic pain, or infertility. This is very useful in cases of adenomyosis.
  • Laparoscopy: A laparoscopy provides visualization of the abdomen and pelvic cavity through an instrument known as the laparoscope. Performed under general anesthesia, the laparoscope is inserted through small incisions made in the abdominal and pelvic cavity, which are sutured back together after surgery. The goal of this technique is to make small incisions in order to ensure minimal invasion. This method allows your surgeon to inspect the abdominal and pelvic regions (and beyond, as needed) to diagnose and subsequently remove endometrial lesions, utilizing his or her surgical modality and tool of choice (for example, laser or excision clippers).

Why is endometriosis difficult to diagnose?

Endometriosis exists in different forms with different symptoms, signs, and prognoses. Though an increased awareness of the disease has given rise to an increase in diagnoses, endometriosis remains a seldom recognized and poorly understood illness. Confusion about appropriate management continues to surround the disease.

How is endometriosis formally diagnosed?

The only way to formally confirm a diagnosis of endometriosis is through surgical biopsy
The only way to formally confirm a diagnosis of endometriosis is through surgical biopsy, which is collected in the operating room as the patient undergoes laparoscopic deep excision surgery.

Despite advances in diagnostic technology and other presurgical imaging tests that help determine whether or not a patient may have endometriosis, a confirmation of endometriosis requires surgical biopsy. This is commonly obtained through minimally invasive laparoscopy.

Are there other ways to formally diagnose endometriosis?

The use of ultrasounds, magnetic resonance imaging (MRI), computerized tomography (CT scan), and certain endometrial biopsy samples may be used as part of a diagnostic workup, but to date, anything less than surgical confirmation of endometriosis is considered uncertain. There are also no specific blood tests to diagnose endometriosis.

Our Approach

What is our approach to diagnosing endometriosis pre-surgery?

Physical Exam: There are a variety of tests that we perform to diagnose endometriosis before a patient has surgery. After your symptoms, history, and complaints are well noted during an examination, we will conduct a thorough physical exam. A thorough physical exam consists of a comprehensive pelvic exam which includes inspecting the cervix, checking for neuropathy in your lower back and legs, assessing costovertebral angle (CVA) tenderness, and evaluating the upper vagina with digital palpation. We evaluate the nodularity, thickening, and shortening of the uterosacral ligament, rectovaginal, cul-de-sac, and lateral vaginal walls in this manner. The tenderness of these areas is significant in measuring the extent of the disease. We will also perform a gentle, single digital pelvic bimanual examination as well as note the mobilization and tenderness of the cervix to touch during this exam (CMT, or cervical motion tenderness). We will then evaluate the anterior and posterior cervix and the upper vagina with digital palpation.

Transvaginal Ultrasound: For patients experiencing painful bowel movements, we perform a transvaginal rectovaginal sonogram (transvaginal ultrasonography or transvaginal ultrasound) on top of a physical exam. Transvaginal ultrasound performed after a bowel preparation improves the ability to properly diagnose intestinal lesions and provides invaluable details including which layers of the intestine are affected and the distance between the lesion(s) and the anal border. We carefully evaluate the uterine walls, endometrial canal, and endometrial cavity for the presence of adenomyosis, fibroids, and polyps. We then scan the cul-de-sac and rectovaginal septum. Finally, it is important to inspect the ovaries. Having treated women with endometriosis for nearly three decades, we strongly believe that ovarian cancer is directly associated with endometriosis. Transvaginal ultrasounds have consistently proven to be the most promising imaging method for the routine screening of ovarian cancer. It is also very effective in screening for endometriosis.

Sonohysterography: We use sonohysterography along with an ultrasound to produce detailed images of the uterine cavity in order to aid in identifying endometrial lesions of submucosal fibroids and polyps, particularly in patients with a history of infertility and heavy periods, regardless of their pain.

What is our approach to diagnosing endometriosis during surgery?

Hysteroscopy: Before any excision surgery, we will conduct a hysteroscopy in order to visualize the lining of the uterus (endometrium), allowing us to see if there is any uterine cause for heavy menstrual bleeding, pelvic pain, or infertility.

Laparoscopy entails visualization of the abdomen and pelvic cavity through an instrument known as the laparoscope
During laparoscopy, three incisions are made into the abdomen and pelvic region. A tube is inserted into the first incision site in order to fill the abdomen with gas, giving more open space to operate. The laparoscope is then inserted into the second hole. Finally, a grasper can be placed into the third incision site.

Laparoscopy: Following your hysteroscopy, we make small incisions into the abdominal and pelvic region. We then insert a laparoscope into the incision sites and the images are depicted on two monitors, one for the surgeon and one for the attending resident. All surgeries we conduct are done via laparoscopy. This allows us to clearly visualize any suspected endometriosis lesions.

ABC technique (™): The Aqua Blue Contrast Technique (ABC) is a patented surgical technique that we use during laparoscopic excision surgery in order to clearly visualize endometriosis scar tissue with an aqua blue contrast solution. While some lesions may be invisible to the typical surgeon using a laparoscopic light, the ABC technique eliminates light reflection in order for the surgeon to visualize, and thus identify and fully excise endometriosis lesions. This method ensures that we identify all areas of endometriosis development throughout the body. This diagnostic tool is strictly unique to us.

Dr. Seckin’s patented ABC contrast allows us to easily see endometriosis scar tissue during laparoscopic deep-excision surgery
Dr. Seckin’s patented ABC technique allows us to easily see endometriosis scar tissue during laparoscopic deep-excision surgery, which is key in identifying and fully excising endometriosis tissue.

So many patients diagnosed with endometriosis undergo multiple surgeries, only for their symptoms to return. Often this occurs because every endometriosis lesion has not been identified and a considerable amount of scar tissue is left behind. In order to ensure a thorough and successful surgery, it is crucial for you to ask the right questions about your surgery, and to learn how your surgeon will identify and excise endometriosis lesions.

Using common diagnostic tools such as ultrasound, MRI, and hysteroscopy, in combination with our unique method of laparoscopy using the ABC technique, we ensure that no visible endometriosis lesion goes undetected. But on top of these diagnostic tools, the first step in identifying your endometriosis is through proper communication.

Ready for a Consultation?

Our endometriosis specialists are dedicated to providing patients with expert care. Whether you have been diagnosed or are looking to find a doctor, they are ready to help.

Our office is located on 872 Fifth Avenue New York, NY 10065.
You may call us at (212) 988-1444 or have your case reviewed by clicking here.





What are the symptoms of endometriosis?

What are the symptoms of endometriosis?

How would I know if I have endometriosis? It can be very difficult for any woman, regardless of her…

Read More

Misdiagnosis of Endometriosis

Why is endometriosis often misdiagnosed? There is a multitude of misdiagnoses that doctors will assign…

Read More
Misdiagnosis of Endometriosis

Patient Reviews

Previous Next