Global trends in the uptake of specialist diagnostic ultrasound and MRI scans for endometriosis: An international cross-sectional survey

JCA: Writing—original draft, review and editing, questionnaire development, data interpretation, validation. AF: Methodology, questionnaire design, data analysis, data interpretation, writing, review and editing of the manuscript. AD, SMN, LH, AB, EGT, TT, JM, DF, EB, NP, EM: Survey distribution, review and editing of the manuscript. ML: Survey design, distribution, review and editing of the manuscript. MLH: Conceptualization, methodology, questionnaire development, data interpretation, validation, review and editing of the manuscript.

Nikhil Purandare (chair) (Ireland), Jaideep Malhotra (past chair) (India), Jackline Akol (South Sudan), Andres Calle (Ecuador), Akira Iwase (Japan), Togas Tulandi (Canada), Craig Niederberger (USA), Edgar Mocanu (Ireland), Ivonne Diaz Yamal (Columbia), Hrishikesh Pai (India).

The survey attracted 445 responses: 360 respondents completed the full questionnaire and 85 began but did not complete the survey. The majority of respondents were female (63.9%) and most responses were in English (76.3%) (Table  2 ). Respondents were spread across all six continents (Figure  1 ). The countries with the most responses were Canada (13.6%), Colombia (10.3%), USA (10.0%), Australia (5.3%), Pakistan (7.5%), UK (3.1%), and India (2.8%). It is unclear how representative of the gynecology and sonography population this was, as one of the objectives of the paper was to describe this population. A full list of all 66 countries included is available in Appendix  A . Demographics ( n  = 360). One missing. Flow chart of survey responses and continent distribution. When asked about professions, roles, and qualifications, respondents self‐classified as gynecologists (20.1%), medical doctors (18.7%), general practitioner/family physicians (11.1%), and obstetrician/gynecologists (10.6%). The majority worked in public hospitals (22.3%), universities (20.1%), or private clinics (18.7%). Regarding qualifications, 83.6% were qualified as gynecologists, with 4.4% stating they were sonographers and 3.1% stating they were radiologists (Table  3 ). Profession and workplace descriptors ( n  = 360). One missing. When asked whether clinicians used non‐invasive imaging to evaluate endometriosis before surgery in their country, 93.6% answered affirmatively. The most commonly used diagnostic method was ultrasound (77.8%) followed by MRI (41.4%), with clinical symptoms (34.4%) and surgery (33.0%) occurring similarly (Table  4 ). In each continent, over 90% of clinicians reported using non‐invasive imaging to evaluate endometriosis before surgery, except in Africa where this was 82.6%. Diagnosis of endometriosis ( n  = 360). Abbreviation: MRI, magnetic resonance imaging. Multiple‐choice answers. Two missing. Of the respondents, 51.1% considered themselves leaders and 39.2% undertook research in this field. The main group that diagnosed endometriosis in particular countries were gynecologists (95.0%), followed by radiologists (15.0%). However, when asked about the main clinician group diagnosing endometriosis, gynecologists were overwhelmingly identified (over 89% in all continents). Radiologists were predominantly the second most common group in all continents, with rates above 10%, with the exception of Africa where 26% specified radiologists. In Oceania, sonographers were the second main group diagnosing endometriosis (17% compared to 9.0% for radiologists) (Figure  2 ). Main clinician group that diagnoses endometriosis by continent. The majority of respondents in most continents (>75%) specified there were gynecologists who undertook specialist endometriosis TVUS; however, in Africa (52.0%) and Asia (58.0%), over half of respondents did not think this. Lastly, 13.0% of African respondents specified that they did not know. When responses by continent were explored, the primary diagnostic methods by country indicated that ultrasound is the primary diagnostic method, with the highest proportion of respondents specifying this as the main method in Asia (89.2%), South America (83.6%), Europe (77.2%), USA (68.9%) Oceania (69.6%), and Africa (60.9%) (Figure  3 ). In most continents, the second most commonly used method varied between MRI, as specified by respondents from Europe (64.9%), South America (46.6%), and Africa (43.5%), with clinical symptoms in North America (50.0%), and surgery in Oceania (73.9%) and North America (44.4%). Diagnostic method used for endometriosis diagnosis by continent. When asked whether gynecologists in their country undertook specialist TVUS for the diagnosis of endometriosis, 75.0% replied affirmatively; however, only 19.0% stated that gynecologists required a specialist qualification to do this. When broken down by continent, the proportions of respondents reporting gynecologists with specialist qualifications were as follows: 92.0% in South America, 79.0% in North America, 58.0% in Asia, 81.0% in Europe, 83.0% in Oceania, and 52.0% in Africa. The proportion of clinicians who used imaging tools was primarily unknown (25.3%); however, 21.4% thought that 100% of clinicians used imaging and 21.4% thought 80% used imaging. In addition, 49.2% thought that imaging was used to diagnose endometriosis “only in certain centers”, while 42.8% thought it was “broadly used”. Overall, 60.0% of respondents felt confident in distinguishing between specialist endometriosis scans and routine ultrasounds or MRI scans (Table  4 ). Participants were asked to report on any barriers using non‐invasive imaging for diagnosing endometriosis and whether its use would have any change in their practice. A total of 12 topics emerged, seven from the first open‐ended question and five from the latter (Table  5 ). The main challenge identified was “lack of training and expertise”, particularly among gynecologists, followed by “cost and accessibility issues”. Topics emerged from content analysis. When participants were asked whether the use of imaging in diagnosis endometriosis would change their practice, the majority of responses came from gynecologists, with most relating to the general impact on clinical practice, surgical and medical management, and shifts in diagnostic approach. Less emphasis was placed on patient‐centered care and systemic challenges, highlighting areas for potential improvement in training, access, and service delivery.

This comprehensive international survey examined global clinician practices regarding the non‐invasive diagnosis of endometriosis, particularly in light of recent changes in clinical guidelines. Over 90% of clinicians used non‐invasive imaging before surgery, with the majority of diagnoses made using ultrasound performed by gynecologists. MRI was used in nearly 40% of cases, while both clinical symptoms and surgery contributed to over one third of cases. Whether these practices reflect updated recommendations from societies such as ESHRE 13 remains unclear, as this was topic was not addressed. However, the adoption of ultrasound has become increasingly widespread due to advances in technique and technology, improving the accuracy of lesion detection—from deep endometriosis to superficial disease—without the need for initial diagnostic laparoscopy. 25 Although ultrasound imaging has been a cornerstone of gynecological care for decades, its use has recently evolved. Incorporation of ultrasound training is now commonplace in specialist training for gynecologists internationally. Subspecializations of dedicated gynecological sonologists (a medical practitioner, who specializes in diagnostic ultrasound) are more common in many locations, with dedicated fellowship programs and qualifications, such as the Australasian Certification in Obstetrical and Gynaecological Ultrasound (COGU). Furthermore, the understanding of ultrasound's utility for diagnosing endometriosis and mapping disease before surgery has improved with the publication of the International Deep Endometriosis Analysis (IDEA) consensus statement from 2016, 12 along with subsequent recent addendums. 26 , 27 Differences still exist between countries and continents. This is due to geographical nuances in healthcare services, such as field leadership, access to clinicians and technicians, education, healthcare funding, accessibility, and technology costs. It is also important to acknowledge that the cost of non‐invasive imaging varies across modalities and health system contexts, with MRI typically being more expensive than ultrasound, which may influence accessibility and clinical uptake in different countries. Cultural norms and beliefs can impact both clinician and patient engagement with imaging technologies. Despite global differences in use of diagnostic ultrasound, all continents predominantly utilized ultrasound, with Asia and South America having the highest adoption rates. Global differences in the use of diagnostic ultrasound exist. In many countries, gynecological ultrasound is performed and interpreted by gynecologists. In others, such as Australia, USA, UK, and Canada, ultrasound is performed by a sonographer and interpreted by a radiologist. These differences make comparisons of global practices challenging, highlighting the necessity of ensuring that global guidelines cater to all relevant healthcare professionals and that training is accessible to all relevant diagnosticians, irrespective of profession. A number of barriers to uptake of non‐invasive imaging could be addressed. Training and education are increasingly necessary for specialized sonographers to free up gynecologists, increasing access to diagnosis via non‐invasive imaging. However, some countries have not yet implemented this model. Further, shifting the diagnosis of endometriosis toward primary health care can accelerate timely intervention. This transition must be supported by improved access to non‐invasive imaging modalities to enable earlier, more accurate identification of disease. Tools like artificial intelligence (AI) can help, not only with teaching but as a virtual mentor when expert supervision is unavailable. 28 Given the wide variations in health system models, costs for specialized endometriosis scans should be set at levels that are affordable for patients. Given this change in practice, the updating of diagnostic guidelines, 13 increase in ultrasound education for clinicians to obtain an endometriosis diagnosis, and advent of diverse AI tools to assist in use of ultrasound and MRI, 25 , 29 it would be prudent to undertake this survey again in the coming years to assess temporal changes in the uptake of new diagnostic techniques. The advantages of non‐invasive imaging include greater accessibility to diagnosis, which may increase the quality of life for women with endometriosis. Furthermore, by reducing the need for surgical procedures for diagnosis, economic benefits will emerge for patients, and pressure and costs on healthcare systems will be reduced. 30 However, we need to ensure that the quality of the diagnostic imaging tools used is maintained. These examinations should only be undertaken by professionals with adequate training in this type of imaging. The strengths of this study include engagement of a large number of respondents globally; however, this did not necessarily relate to population proportions. The survey was equally completed by both those who considered themselves field leaders and those who did not. Some limitations include the proportion of the sample that did not complete the survey and were thus deemed ineligible. Many valuable data were collected from this part of the sample; however, we could not analyze it further due to lack of consent. As most FIGO members are gynecologists, our sample predominantly reflects this. Over one third of respondents also conducted research in the area, indicating high level investment and interest. This could introduce bias, as we only surveyed people within the field who have a special interest in this area. In addition, practices in some countries regarding which practitioners undertake endometriosis scans vary substantially. This means that many of the questions we asked may have not pertained to particular countries. For example, Australia has sonographers who undertake endometriosis scans; however, many European countries do not. Further, we acknowledge that differences in clinical background and health system contexts among countries may influence responses. This study demonstrates the need for training in diagnostic modalities and interpretation and reinforces awareness of their utility. In the future, it would be valuable to target specific professions that undertake diagnostic exams for endometriosis, not only gynecologists and radiologists, but sonographers and family doctors as well. Future surveys can explore imaging for therapeutic purposes of endometriosis as well as co‐morbidities and individuals using artificial reproductive techniques with the intention of pregnancy. There is a need to assess and regulate the quality of testing. As these imaging tests become more accessible, especially with funding body rebates for patients, more clinics may claim to offer the service without any verification of completed training. This highlights the importance of credentialing imaging providers, ensuring that both patients and funding bodies receive the services they are paying for. Ultimately, the successful integration of non‐invasive imaging into standard diagnostic pathways for endometriosis requires not only technological advancement but also coordinated efforts in education, policy, and clinical governance.

This study highlights how specialist endometriosis scanning has influenced clinical practice and identifies areas where additional training or resources are needed. Recent guidelines from ESHRE, NICE, and other professional bodies recognize TVUS and MRI as non‐invasive approaches for identifying endometriosis lesions, although these methods cannot fully exclude the disease. Raising awareness and addressing gaps in knowledge and skills will improve access to non‐invasive diagnosis. Earlier diagnosis is likely to benefit the endometriosis community by reducing symptom normalization and diagnostic delays, while supporting treatment optimization, school attendance, and work productivity. Additional potential benefits of early diagnosis include preventing the development of complex pain syndromes and preserving fertility through timely intervention.

Endometriosis affects approximately 1 in 10 women and those presumed female at birth worldwide, occurring when endometrium‐like tissue grows outside the uterus. 1 Despite menstrual pain often beginning at menarche, diagnostic delay is common, averaging 6.8 years (range 1.5–11.4 years), 2 though country data remain limited. Traditionally, diagnosis has been restrained by availability of diagnostic surgery, lack of training among specialist doctors and technicians, different funding and insurance models, and specialist and surgical waiting lists disrupted by global events such as pandemics. Over their diagnostic journey, women often see six or more health professionals, 3 having repeated interactions with health services, creating economic burden for both individuals and health systems. 4 Historically, laparoscopic surgery has been the mainstay of endometriosis diagnosis. 5 However, surgical diagnosis presents significant challenges, including long waiting periods and high costs. 6 Importantly, one third of people who undergo laparoscopy to investigate endometriosis do not receive a diagnosis, exposing them to an unnecessary and risky procedure. 7 Systematic reviews of blood, urine, and endometrial tissue biomarkers for endometriosis demonstrate insufficient diagnostic accuracy for effective clinical use. 8 Recent advances include the evaluation of microRNA biomarkers in plasma, 9 saliva, 10 and proteomics plasma profiles. 11 Some studies show diagnostic promise, yet current evidence remains insufficient for routine clinical use. Diagnostic imaging for endometriosis has evolved significantly recently, with transvaginal ultrasound (TVUS) 12 and magnetic resonance imaging (MRI) 13 demonstrating high levels of diagnostic accuracy for deep and ovarian endometriosis. 8 International guidelines from societies, such as European Society of Human Reproduction and Embryology (ESHRE), 13 National Institute for Health and Care Excellence (NICE UK), 14 Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), 15 and Society of Obstetricians and Gynecologists of Canada (SOGC), 16 now recommend imaging in the diagnostic workup for endometriosis, noting that a negative imaging finding does not exclude a diagnosis of endometriosis. Country‐specific surveys have documented the uptake of imaging as a primary diagnostic tool for endometriosis. These are summarized in Table  1 ; however, worldwide practices have not been well documented. 17 , 18 , 19 , 20 , 21 The aim of the present study was to explore the global adoption of non‐invasive imaging techniques, specifically ultrasound and MRI, in the diagnosis of endometriosis, by analyzing clinician‐reported experiences across health systems. The study investigates how greater uptake of imaging could influence clinical practice, aiming to inform future diagnostic guidelines and training models. Barriers and facilitators for the uptake of non‐invasive imaging and differences between continents were also explored but will be addressed in a separate paper. International surveys around endometriosis diagnosis using imaging. Need for standardization of MRI techniques for endometriosis as many centers were not compliant with current evidence when significant inconsistencies in MRI protocols, patient preparation, and MRI sequences performed were identified A delay in adopting novel diagnostic approaches in endometriosis, and confirmed urgent need for specialized ultrasound training 38% reported that they or their institution performed advanced pelvic ultrasound for endometriosis 70% stated they currently interpret pelvic endometriosis MRI However, many centers did not perform the specialized scanning required to detect endometriosis Utilization of advanced gynecological ultrasound for endometriosis is significantly influenced by respondents' self‐reported practice type and limited by the lack of local expertise Poor awareness and underutilization of specialist endometriosis ultrasonography calling for increased resource allocation for its use in surgical triaging Significant gaps in the understanding of diagnosing endometriosis non‐surgically Abbreviation: MRI, magnetic resonance imaging.

JCA and AF are funded by a 2021 MRFF PHRDI Grant from the Commonwealth of Australia for IMAGENDO®. AD is funded by a Research Training Program Stipend from the University of Adelaide and a research training program fee offset scholarship from the Australian Commonwealth Government. ML reports consulting fees from AbbVie, Hologic, Imagendo, and Chugai Pharmaceutical; personal fees from GE Healthcare, Bayer, TerSera, and AbbVie; and grants from CanSAGE, AbbVie, AIMA/SOPHIE, Hyivy/MITACS/SOPHIE, Hamilton Health Sciences, Endometriosis Australia, Medical Research Future Fund/ IMAGENDO®, and Health Canada outside the submitted work. MLH is a PI on IMAGENDO®, a University‐based research initiative. She has an MRFF grant from the Australian government. The IMAGENDO® group is developing an AI based diagnostic algorithm for endometriosis scanning, holding a Patent PCT/AU2024/050999. She has received travel grants from Gideon Richter, MERCK, Organon, Bayer, Ferring and Guerbet.

Between September and October 2024, an international online, cross‐sectional survey was distributed via the International Federation of Gynecology and Obstetrics (FIGO) and regional networks accessed by members of the FIGO Committee on Reproductive Medicine, Endocrinology, and Infertility (REI). A convenience sample included healthcare professionals involved in the diagnosis of endometriosis. The survey aimed to capture a snapshot of practices undertaking endometriosis diagnosing across continents. Specific questions were asked about health personnel who used non‐invasive endometriosis diagnosis and techniques. Multiple‐choice and open‐ended questions were included. Demographic questions were asked at survey commencement, including questions on jurisdictional leadership and research in the field. The 10 core questions are presented in Box  1 . The order of the questions was structured to follow a logical order from broad to more specific. Questions 1–3 establish who is responsible for diagnosing endometriosis and whether non‐invasive imaging is being used in this context. This is followed by more detailed questions concerning specialist training and confidence in interpreting imaging findings (questions 4–8). Finally, participants are invited to reflect on perceived barriers and potential changes in their own country (questions 9 and 10). This sequence was introduced to ensure coherence and consistency, while minimizing the risk of introducing bias through question order. 1. In your country, who are the main group of clinicians that diagnose endometriosis? 2. In your country, are clinicians using non‐invasive imaging to evaluate endometriosis before surgery? 3. Which diagnostic method is predominantly used in your country? 4. Do you have gynecologists who undertake specialist endometriosis transvaginal ultrasound? 5. If yes, do they require a qualification and/or credentialling to perform these scans? 6. Do you feel confident distinguishing between specialist endometriosis scans and routine ultrasounds and/or MRI scans? 7. What proportion of clinicians is using imaging tools for the diagnosis of endometriosis in your country? 8. In your country, how widespread is the use of imaging to diagnose endometriosis? 9. What are the barriers for using imaging in endometriosis diagnosis? 10. If imaging was adopted for endometriosis diagnosis in the future, how would it change your practice? 1. In your country, who are the main group of clinicians that diagnose endometriosis? 2. In your country, are clinicians using non‐invasive imaging to evaluate endometriosis before surgery? 3. Which diagnostic method is predominantly used in your country? 4. Do you have gynecologists who undertake specialist endometriosis transvaginal ultrasound? 5. If yes, do they require a qualification and/or credentialling to perform these scans? 6. Do you feel confident distinguishing between specialist endometriosis scans and routine ultrasounds and/or MRI scans? 7. What proportion of clinicians is using imaging tools for the diagnosis of endometriosis in your country? 8. In your country, how widespread is the use of imaging to diagnose endometriosis? 9. What are the barriers for using imaging in endometriosis diagnosis? 10. If imaging was adopted for endometriosis diagnosis in the future, how would it change your practice? The final survey was administered on SurveyHero©, distributed internationally via FIGO's email lists, the American Association of Gynecologic Laparoscopists (AAGL), Australian Society of Ultrasound in Medicine (ASUM), and social media, including the IMAGENDO® Facebook and Instagram pages. The average completion time was approximately 7 minutes. Consent was obtained as part of the survey preamble, before commencing the survey. If consent was not stated, the survey would not proceed. Participants were required to be aged over 18 years and a healthcare professional providing reproductive services. The survey was disseminated in the three official FIGO languages (French, Spanish, and English). Descriptive statistics included counts (n) and percentages (%) for categorical data generated using statistical programs (i.e. STATA). Analyses described sample characteristics (e.g. gender, role, qualifications, country, etc.). Frequencies were presented for all responses regarding demographics, profession and location of practice, and endometriosis diagnosis, with cross‐analyses for selected questions undertaken by continent. Open‐ended questions were analyzed using content analysis to identify emerging topics, the results of which will be published in another paper. The survey was approved by the FIGO REI Committee and the University of Adelaide Human Research Ethics Committee (protocol approval no. H‐2024‐031) in compliance with the STROBE and CROSS statements and checklists (Appendices  B and C , Tables  A1 and A2 ). 23 , 24