{"paper_id":"54d886b9-bccf-4a64-90c2-ae5c4db3a458","body_text":"Orginal Article  | JOGCR. 2026; 11(8): 713-719 \n     Volume 11, May 2026       Journal of Obstetrics, Gynecology and Cancer Research \n Journal of Obstetrics, Gynecology and Cancer Research | ISSN: 2476-5848 \n \n \nDiagnostic Value of Imaging Findings Compared with Pathology in the \nDiagnosis of Endometriosis \n \nArian Karimi Rouzbahani1,2 , Golnaz Mahmoudvand3 , Mohammad Amin Khazeei Tabari4,5, \nSamaneh Norouzi Cholcheh6 , Mania Beiranvand7, Mohammad Kazem Shahmoradi7, \nMohammad Heidarian8* \n \n1. Western Health, Department of Urology, Melbourne, Australia \n2. Surgery Education and Researching Network (SERGN), Universal Scientific Education and Research Network (USERN), \nKhorramabad, Iran \n3. USERN Office, Lorestan University of Medical Sciences, Khorramabad, Iran \n4. Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran  \n5. USERN Office, Mazandaran University of Medical Sciences, Sari, Iran \n6. Student Research Committee, Lorestan University of Medical Sciences, Khorramabad, Iran \n7. Department of General Surgery, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran \n8. Department of Internal Medicine, School of Medicine, Shahid Rahimi Hospital, Lorestan University of Medical Sciences, \nKhorramabad, Iran \nArticle Info  ABSTRACT \n  \n 10.24200/jogcr.11.8.713 \n \n \n \nBackground & Objective:  Laparoscopic and histological evaluation is the most \nreliable method for confirming the presence of endometriosis; nevertheless, imaging \nmethods may provide useful information. In this study, the diagnostic value of imaging \nfindings for the diagnosis of endometriosis was compared with that of pathology. \nMaterials & Methods: This cross-sectional study was conducted in Khorramabad, \nLorestan, Iran. The imaging results of 118 patients with symptoms of endometriosis \nwho had undergone ultrasound, Computed Tomography (CT) scan, and Magnetic \nResonance Imaging (MRI), and who had a positive result suggestive of endometriosis \nin at least one of the three modalities, were compared with their pathology reports. \nAdditionally, information such as the history of cesarean section, delivery, laparoscopic \nprocedures, marital status, and type of lesion was collected and analyzed. \nResults: In this study, the sensitivity of ultrasound for the diagnosis of endometriosis \nwas 93.2%. The sensitivity of MRI for the diagnosis of endometriosis was 98.3%. CT \nscan had the lowest sensitivity among these three modalities, at 65.8%. \nConclusion: Based on the results of this study, ultrasound and MRI have a remarkable \nability to diagnose endometriosis with the least number of false negatives due to their \nhigh sensitivity. Given their limited sensitivity and high radiation exposure, the use of \nCT scans for diagnosing endometriosis in the abdominal and pelvic cavities is not \npractical. \nKeywords: CT scan, Endometriosis, Imaging, MRI, Ultrasound  \n \nReceived: 2024/04/06 \nAccepted: 2024/09/15 \nPublished Online: 28 Jun. 2026 \n \n \n \n \n \nCorresponding Information:  \nMohammad Heidarian, \nDepartment of Internal Medicine, School of \nMedicine, Shahid Rahimi Hospital, Lorestan \nUniversity of Medical Sciences, Khorramabad, \nIran \n \nEmail: ammadheidarian139@gmail.com \n \n \nCopyright © 2025, This is an original open -access article distributed under the terms of the Creative Commons Attribution-noncommercial \n4.0 International License which permits copy and redistribution of the material just in noncommercial usages with proper citation . \n \n \n1. Introduction\nEndometriosis arises when endometrial glands and \nstroma are present outside the uterus (1). Although \nlesions are typically limited to the pelvis, they can also \nappear in the bladder, diaphragm, and pleural cavity \n(2). Although endometriosis is a benign condition, the \npresence of ectopic endometrial tissue and the \ninflammation it causes can impair menstruation and \nresult in persistent pelvic discomfort and infertility. \nThe severity of the symptoms may range from minor to \nsevere (3). \nThe precise prevalence of endometriosis in the \noverall population has not been determined and varies \ndepending on the study population as well as the type \nof diagnostic approach (clinical or surgical) (4). \nNevertheless, endometriosis is estimated to affect 10% \nof women of reproductive age. The prevalence of \nendometriosis remains debatable because some \npatients are asymptomatic or present with vague \nsymptoms, and a definitive diagnosis requires a \nsurgical biopsy (3). \nDiagnostic laparoscopy and histological \nconfirmation of suspected lesions are the only valid \ndiagnostic methods for endometriosis. However, \nhistological evaluation of endometriosis is not always \n\n\nArian Karimi Rouzbahani, et al. 714 \n      Volume 11, May 2026       Journal of Obstetrics, Gynecology and Cancer Research \nreliable (5), because it may be inconclusive for \nmacroscopic or microscopic peritoneal lesions (6). \nBecause surgery is expensive and potentially \nharmful, non -invasive diagnostic approaches such as \nimaging and biomarkers are widely used as alternative \ntools for clinical evaluation (7). A reliable noninvasive \ntest can avoid the need for surgery or limit its use to \npatients who are most likely to have endometriosis (6). \nEarlier diagnosis of endometriosis may improve \npatients’ quality of life by reducing diagnostic delay \nand allowing timely treatment. Noninvasive imaging \nmodalities such as transvaginal ultrasound and MRI \nplay an important role in the early detection of \nendometriosis due to their accessibility, safety, and \ncost-effectiveness (8). Given  the importance of \nimaging modalities in diagnosing endometriosis, we \ncompared the sensitivity of imaging findings, including \nComputed Tomography (CT) scans, ultrasound, and \nMagnetic Resonance Imaging (MRI), with the \npathology and histological findings of patients with \nendometriosis. \n \n2. Materials and Methods \nStudy Population  \nThe study population consisted of 118 women who \nwere referred between 2018 and 2021 with clinical \nsigns of endometriosis (chronic pelvic pain, \ndysmenorrhea, painful and palpable abdominal mass, \nor infertility) and who had undergone different imaging \nmodalities and biopsy for definitive diagnosis. All \npatient information was kept confidential, and no \npersonal information was included in the study. The \nethics code was obtained from the Ethics Committee of \nLorestan University of Medical Sciences \n(IR.LUMS.REC.1400.230). \nInclusion and Exclusion Criteria \nInclusion criteria included women who were referred \nto medical centers with clinical signs suggestive of \nendometriosis, for whom ultrasound, CT scan, and \nMRI results were available, who had positive imaging \nfindings (in at least one imaging modality), and who \nhad positive pathology results. Subjects without an \navailable pathology report and those who had not \nundergone imaging with all three modalities were not \nincluded.   \nFinally, based on the exclusion criteria, most patients \nwere excluded from the study, and 118 patients were \nselected. \nData Acquisition \nThis study was conducted in Khorramabad, Lorestan \nProvince, Iran. First, a list was prepared of patients \nwith suspected clinical signs of endometriosis who had \nbeen referred to the radiology centers of hospitals in \nKhorramabad for imaging and were diagnose d with \nendometriosis. To maintain confidentiality, an \nidentification code was assigned to each patient. The \npatients' demographic information, past medical \nhistory, and clinical data were recorded. Imaging \ninformation and pathology results were documented \nseparately. Then, the findings of each imaging \nmodality were compared with those of the other \nmodalities as well as with the pathology report of the \nsame patient. \nStatistical Analysis   \nThe data was entered into SPSS statistical software \nversion 22. The sensitivity and specificity of different \nimaging modalities for the diagnosis of endometriosis \nwere compared with pathological findings. Mann –\nWhitney and Chi-square tests were used to analyze the \ndata. A P-value of <0.05 was considered statistically \nsignificant. \n \n3. Results \nPatients were analyzed (Figure 1). \nDescriptive Analysis Results \nIn this study, among 118 patients, the maximum age \nwas 49 years, the minimum age was 15 years, and the \nmean age of patients with endometriosis was 31.14 \nyears. The number of married patients was 92 (78%). \nMost of the patients (68.6%) had a history of cesar ean \nsection. A total of 81 patients (68.6%) had a history of \ndiagnostic laparoscopy (Table 1). \nImaging Findings \nAll patients had undergone an ultrasound. In 90 \npatients (76.3%), a transvaginal ultrasound had been \nperformed, and in 28 patients (23.7%), a \ntransabdominal ultrasound had been performed. The \nmost frequently reported disorder on ultrasound was \ncystic lesions (n=87, 73.7%). \nIn the CT scans of patients, hypodense lesions were \nreported in 60 cases (50.8%). \nBased on MRI reports, 92 cases (78%) showed \nhypersignal lesions in both phases, and 24 cases \n(20.3%) were hypersignal in T1 and hyposignal in T2. \nNo cases were reported as hyposignal in both phases \n(Table 2). \nPathology Findings \nIn this study, all 118 patients had pathology results \nconfirming endometriosis. The pathology findings \ndemonstrated that 90 patients (71.3%) had ovarian \ninvolvement, 38 patients (32.2%) had uterosacral \nligament involvement, and 48 patients (40.7%) had cul-\nde-sac involvement. The results also showed that 13 \npatients (11%) had cesarean section scar endometriosis. \nFurther information is shown in Table 3.   \nClinical Findings \nThe clinical findings demonstrated that chronic pelvic \npain was the most common symptom, observed in 81 \n\n715 Imaging vs Pathology Findings in Endometriosis \n      Volume 11, May 2026       Journal of Obstetrics, Gynecology and Cancer Research \npatients (68.6%). In all cases, the patients’ pathology \nresults confirmed endometriosis (Table 3). \nSpecificity and Sensitivity Calculation \nIn this study, the sensitivity of ultrasound for the \ndiagnosis of endometriosis was 93.2%. The sensitivity \nof MRI for the diagnosis of endometriosis was 98.3%. \nCT scan had the lowest sensitivity among these three \nmodalities, at 65.8%. As the pathology results of all \npatients were positive for endometriosis and patients \nwith negative results were excluded, the specificity and \nP-value for the other variables could not be calculated. \n \nTable 1. Demographic and clinical characteristics of the patients \nCharacteristic Frequency Percentage \nAge  ≤30 \n>30 \n63 \n55 \n53.4% \n46.6% \nMarital status \n \nMarried \nSingle \n92 \n26 \n78.0% \n22.0% \nType of birth  \n \nCesarean \nNatural birth \n81 \n37 \n68.6% \n31.4% \nHistory of diagnostic \nlaparoscopy  \nNo \nYes \n37 \n81 \n31.4% \n68.6% \n \nTable 2. Imaging findings in the studied patients \nImaging modalities Frequency Percentage \nUltrasound  \n \nTransvaginal  \nTransabdominal \nCystic lesion \nSolid lesion \nAdhesion \nNormal  \n90 \n28 \n87 \n16 \n8 \n7 \n76.3% \n23.7% \n73.7% \n13.6% \n6.8% \n5.9% \nCT scan \nHypodense lesion \nHyperdense lesion \nNormal \n60 \n18 \n40 \n50.8% \n15.3% \n33.9% \nMRI \n \nHypersignal in T1 and T2 \nHypersignal in T1 and hyposignal in T2 \nHyposignal in T1 and T2 \nNormal \n92 \n24 \n0 \n2 \n78% \n20.3% \n0% \n1.7% \n\nArian Karimi Rouzbahani, et al. 716 \n      Volume 11, May 2026       Journal of Obstetrics, Gynecology and Cancer Research \nTable 3. Pathology and clinical findings of endometriosis patients \nPathology and clinical findings Frequency Percentage \nOvarian lesion No  \nYes  \n28 \n90 \n23.7% \n76.3% \nUterosacal ligament involvement No  \nYes   \n80 \n38 \n67.8% \n32.2% \nColdosac's involvement No  \nYes  \n70 \n48 \n59.3% \n40.7% \nCesarean’s scar No  \nYes \n105 \n13% \n89% \n11% \nUmbilical involvement No  \nYes \n115 \n3 \n97.5% \n2.5% \nBladder involvement   No  \nYes \n117 \n1 \n99.2% \n0.8% \nPelvic wall involvement   No  \nYes \n117 \n1 \n99.2% \n0.8% \nPalpable mass  No  \nYes \n110 \n8 \n93.3% \n6.6% \nChronic pelvic pain No \nYes \n37 \n81 \n31.4% \n68.6% \n \n4. Discussion \nEndometriosis is a relatively common disease that \npresents a wide range of symptoms (9). The gold \nstandard for its diagnosis is diagnostic laparoscopy, a \ncostly and invasive procedure (10). Another diagnostic \napproach, imaging, has been proposed as a low -cost, \nnoninvasive alternative that can greatly reduce the need \nfor diagnostic laparoscopy. So far, the findings of \nseveral studies that have evaluated the sensitivity and \nspecificity of ima ging have been satisfactory. In this \nstudy, we compared the diagnostic outcomes of several \nimaging modalities with their pathological results in an \neffort to assess the utility of imaging. \nIn the present study, which was performed on 118 \npatients, all participants were of reproductive age. Due \nto the positive pathology results in all patients, it was \nnot possible to determine the specificity in comparison \nwith the imaging methods. On ultraso und, \nendometriosis usually appears as a multilocular or \nunilocular cyst with diffuse low-level echoes and a wall \nwith hyperechoic centers (11,12). In this study, 73.7% \nof patients had cystic lesions. In addition, 13.6% of \npatients had a solid lesion on ult rasound. Transvaginal \nultrasound is typically the first choice for examining \npatients with signs of endometriosis, persistent pelvic \ndiscomfort, or infertility, and its results are comparable \nto those of MRI (13,14). In this study, transvaginal \nultrasound had been performed in 90 patients (76.3%). \nUltrasound can also help diagnose abdominal wall \nendometriosis. Although imaging findings alone \ncannot confirm endometriosis, combining these \nfindings with the patient’s symptoms, proximity to the \nsurgical scar site, and the association of symptoms with \nthe patient’s menstruation can make the diagnosis of \nendometriosis more likely (15).  \nIn the CT scan reports of patients, 60 cases (50.8%) \nhad hypodense lesions, and 18 cases (15.3%) had \n\n717 Imaging vs Pathology Findings in Endometriosis \n      Volume 11, May 2026       Journal of Obstetrics, Gynecology and Cancer Research \nhyperdense lesions. Also, in 40 cases (33.9%), a \nnormal CT scan result was reported. According to the \nfindings, the sensitivity of CT scan in the diagnosis of \nendometriosis was 65.8%. Due to the positive \npathology results in all patients, it was impossible  to \ndetermine the specificity. Considering that all \nendometriosis lesions were found in the abdominal \ncavity, the results indicate that the use of CT scan in \ndiagnosing endometriosis in the abdominal cavity is \nlimited. \nIn terms of MRI reports, 92 cases (78%) had \nhypersignal lesions in both phases, and 24 cases \n(20.3%) had T1 hypersignal and T2 hyposignal lesions. \nNo cases were reported as hyposignal in both phases. \nAlso, 2 cases (1.7%) did not have any findings on MRI. \nThis study demonstrated that MRI has a sensitivity of \n98.3% in the diagnosis of endometriosis. The \nspecificity of this modality could not be calculated due \nto the positive pathology results in all patients. In other \nstudies, MRI has also shown high sensitiv ity and \nspecificity in diagnosing endometriosis (16). Because \nthe foci of endometriosis have functional properties, \nthey are affected by hormonal changes during \nmenstruation. Endometriosis foci can show different \nsignal intensities on T1- and T2-weighted images, and \nthese differences are related to the duration of bleeding \nwithin the lesions. Subacute hemorrhage can appear as \nvery high signal intensity on T1 -weighted images, \nwhich is more pronounced on fat -suppressed images. \nThese lesions may appear as low signal intensity on T2-\nweighted images. In women with chronic \nendometriosis, reactive fibrosis increases with \nrecurrent bleeding. Fibrotic endometriosis lesions \nappear as irregular lesions with low signal intensity on \nboth T1- and T2-weighted images. Caref ul evaluation \nfor small foci of high signal intensity on T2 -weighted \nimages, and often on T1 -weighted images, which are \nrelated to dilatation of endometrial glands within \nfibrotic tissue, can be diagnostic because the low signal \nintensity on T2 -weighted im ages of these lesions is \nvery similar to that of the abdominal wall (17,18). \nCollectively, our findings suggest that ultrasound and \nMRI are sensitive modalities for diagnosing \nendometriosis. These findings, along with the high \nradiation dose and low sensitivity of CT scans, indicate \nthat the use of CT scans in the diagnostic appr oach to \nendometriosis of the abdominal and pelvic cavities \nshould be limited.   \nAmong the 118 patients, 81 cases (68.6%) had a \nhistory of diagnostic laparoscopy, while the others did \nnot. In some patients, more than one site of \ninvolvement was present; therefore, the total number of \nlesions based on the site of involvement is greater than \n118.  \nThe most common sites of endometriosis are the \novary, the uterosacral ligaments, the ovarian fossa, the \npouch of Douglas, and the bladder (19). In our study \npopulation of 118 patients, 90 patients (71.3%) had \novarian involvement with endometriosis, while 28 \npatients (23.7%) had no ovarian involvement. Thirty -\neight patients (32.2%) had uterosacral ligament \ninvolvement, whereas 80 patients (67.8%) had no \ninvolvement of the uterosacral ligaments. Forty -eight \npatients (40.7%) had cul-de-sac involvement, while 70 \npatients (59.3%) had no cul -de-sac involvement. In \naddition, 105 patients (89%) had no endometriosis at \nthe site of the cesarean section, whereas 13 patients \n(11%) had endometriosis at the cesarean section site. \nOnly three patients (2.5%) had umbilical involvement, \nwhile 115 patients (97.5%) had no umbilical \ninvolvement. Bladder involvement was observed in \nonly one patient (0.8%). Similarly, only one patient \n(0.8%) had pelvic wall involvement. In a prospective \nstudy of 1101 patients with laparoscopically confirmed \nendometriosis, the most common sites of \nendometriosis were the ovary (67%), uterosacral \nligament (46%), and ovarian fossa (32%). Deep \ninfiltration has also been reported in 14% of patients \nwith endometriosis (19). In some cases, endometriosis \nin the anterior wall of the abdomen, especially at the \nsite of a previous surgical incision, has been reported \n(20). Rarely, endometriosis has also been reported in \nthe breast, pancreas, liver, gallbladder, urethra, \nvertebrae, etc. Most patients have involvem ent at \nseveral sites (3,21). In this study, the ovary, with 71.3% \ninvolvement, was the most common site of \ninvolvement, while the bladder and pelvic wall, each \nwith about 0.8% involvement, had the lowest \nfrequency. No cases of thoracic endometriosis, \ndiaphragmatic, intestinal, or ureteral involvement were \nreported in this study. The prevalence of bladder \nendometriosis was also very low. As described in the \nliterature, bladder involvement in endometriosis has \nbeen reported to be very rare (<1%) (22). \nTransvaginal sonography is recommended as the \ninitial diagnostic method for individuals with signs of \ndeep pelvic endometriosis. Endometriotic cysts can be \nidentified more accurately using transvaginal \nultrasound; however, MRI is superior for diagnosing \nlesions of the torus uterinus, uterosacral ligaments, \nintestine, and bladder. MRI is also the imaging \nmodality of choice for diagnosing intestinal or rectal \nnodules, as well as nodules of the rectovaginal septum \n(23). Moreover, the findings of a meta -analysis \nindicated that transvaginal ultrasound and MRI have \ncomparable diagnostic value for deep infiltrating \nendometriosis. This evidence supports the use of \ntransvaginal ultrasound as the first -line modality for \ndetecting endometriosis (16). \nLimitations  \nThe limitation of the present study is the use of data \nfrom a single center. Therefore, it is recommended that \nsimilar multi-center studies with larger populations be \nconducted to allow for greater generalizability of the \nresults. \n \n5. Conclusion \n\nArian Karimi Rouzbahani, et al. 718 \n      Volume 11, May 2026       Journal of Obstetrics, Gynecology and Cancer Research \nBased on the results of this study, ultrasound and \nMRI have a remarkable ability to diagnose \nendometriosis with the fewest false negatives due to \ntheir high sensitivity. In addition, because of the low \nsensitivity of CT scans and their high radiation dose,  \ntheir use in diagnosing endometriosis of the abdominal \nand pelvic cavities is not recommended. It is \nrecommended that this study be conducted on a larger \nscale with a greater statistical population so that the \nresults have stronger statistical value. This  is because \nnot all types of endometriosis may be observed in a \nsmall study population, and there may also be \nhomogeneity in the distribution of pathology results. \nFor a more detailed evaluation of the sensitivity of \nultrasound, the results of transvaginal  ultrasound \nshould be compared separately with those of \ntransabdominal ultrasound. Finally, it would be \nbeneficial to evaluate MRI results with and without \ngadolinium in a separate study. \n \n6. Declarations \nAcknowledgments \nNot applicable \n \nEthical Considerations \nThis study was approved by the Ethics Committee of \nLorestan University of Medical Sciences \n(IR.LUMS.REC.1400.230). Written informed consent \nwas obtained from all participants before inclusion in \nthe study. All procedures were conducted in \naccordance with t he ethical standards of the \nDeclaration of Helsinki. \n \nAuthors' Contributions \nAKR contributed to data collection; GM and MAKT \ncontributed to drafting the manuscript; SNC \ncontributed to data collection; MB and MKS critically \nrevised the manuscript; and MH conceptualized the \nstudy and finalized the manuscript. All authors read \nand approved the final version of the manuscript. \n \nConflict of Interest \nThe authors attest that they have no conflict of \ninterest to declare. \n \nFund or Financial Support \nThis research received no specific grant from any \nfunding agency in the public, commercial, or not -for-\nprofit sectors. \n \n \n \n \n1. Mohebbi A, Hojati V, Zolbin MM, Aflatoonian \nR. Histopathologic evaluation of the \ninflammatory factors and stromal cells in \nendometriosis lesions: a case‑control study. Int J \nReprod Biomed. 2022;20 (10):819‑30. \n[doi:10.18502/ijrm.v20i10.12266] \n2. 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