Best Practices: Ultrasound Versus MRI in the Assessment of Pelvic Endometriosis
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This review found that dedicated ultrasound and MRI showed similar diagnostic accuracy for pelvic endometriosis, with modality choice depending on regional expertise, though ultrasound better assessed bowel-wall invasion and MRI pelvic-wall disease.
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Abstract
Endometriosis is a common yet morbid disease. Imaging plays an important role in diagnosis and treatment planning. Both ultrasound (US) and MRI are used to detect disease. We performed a literature review to assess whether one is superior. A total of 33 studies from the 4482 identified in the initial search were found to assess the efficacy of US and/or MRI in detecting pelvic endometriosis. Most studies were performed at centers with extensive experience with endometriosis, using dedicated US and MRI protocols. A wide range of sensitivities and specificities were reported, but overall weighted means of diagnostic statistics for US and MRI were similar. The choice of dedicated US versus dedicated MRI in the evaluation of endometriosis should therefore be based on the expertise in the region. The data also showed US had better accuracy than MRI for identifying the depth of wall invasion in bowel-wall disease, whereas MRI better depicted pelvic-wall and extraperitoneal disease than US. Routine US and MRI protocols performed worse than dedicated US and MRI protocols, which may account for delays in diagnoses. Clinical and research efforts directed at improving the sensitivity of routine imaging for diagnosing deep endometriosis could improve patient access to appropriate care.
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Abstract
Clinical Vignettes and Images
The Imaging Question
Background
Epidemiology
Imaging Appearance
Role of Imaging
Imaging Techniques
| Sequence | Plane or FOV |
|---|---|
| T2-weighted TSE without FS | Axial (including small FOV) and sagittal, with or without coronal |
| T1-weighted GRE in- and opposed-phase | Axial |
| DWI with ADC mapping | Axial |
| T1-weighted GRE with FS without IV contrast material | Axial and sagittal, with or without coronal |
| T1-weighted GRE with FS with IV contrast material and subtraction | Axial and sagittal, with or without coronal |
| T2-weighted SSFSE (optional) | Large FOV that includes the kidneys for evaluation of hydronephrosis |
Note—TSE = turbo spin-echo, FS = fat suppression, GRE = gradient-recalled echo.
Synopsis and Synthesis of Evidence
Literature Review
| First Author [Reference] | Year | Risk of Bias | Applicability Concerns | |||||
|---|---|---|---|---|---|---|---|---|
| Patient Sel | Index Test | Ref | Flow and Timing | Patient Sel | Index Test | Ref | ||
| Alborzi [21] | 2018 | High | High | High | High | High | High | High |
| Alborzi [20] | 2023 | High | High | High | High | High | High | High |
| Asgari [22] | 2022 | Low | UC | Low | UC | Low | Low | Low |
| Bartlett [23] | 2020 | Low | Low | High | Low | Low | Low | Low |
| Bazot [25] | 2009 | Low | Low | UC | UC | Low | Low | Low |
| Bazot [24] | 2012 | Low | Low | High | UC | Low | Low | Low |
| Chamié [26] | 2009 | Low | Low | UC | UC | Low | Low | Low |
| Deslandes [27] | 2023 | Low | Low | High | High | Low | Low | Low |
| Di Giovanni [28] | 2022 | Low | Low | UC | UC | Low | Low | Low |
| Fratelli [29] | 2013 | Low | Low | High | Low | Low | Low | Low |
| Goncalves [30] | 2021 | Low | Low | Low | UC | Low | Low | Low |
| Guerriero [31] | 2008 | Low | Low | High | Low | Low | Low | Low |
| Hernández Gutiérrez [32] | 2019 | Low | Low | UC | Low | Low | Low | Low |
| Holland [33] | 2013 | Low | Low | Low | UC | Low | Low | Low |
| Hudelist [34] | 2011 | Low | Low | High | Low | Low | Low | Low |
| Kamkarfar [35] | 2022 | Low | UC | Low | UC | Low | Low | Low |
| Krüger [36] | 2013 | Low | Low | High | Low | Low | Low | Low |
| Manganaro [37] | 2012 | Low | UC | UC | UC | Low | Low | Low |
| Mangler [38] | 2013 | Low | Low | UC | Low | Low | Low | Low |
| Manti [39] | 2022 | Low | Low | UC | UC | Low | Low | Low |
| Padmehr [40] | 2023 | High | High | High | UC | Low | Low | Low |
| Pateman [41] | 2015 | Low | Low | High | UC | Low | Low | Low |
| Pattanasri [42] | 2020 | Low | Low | High | UC | Low | Low | Low |
| Piketty [43] | 2009 | Low | Low | UC | UC | Low | Low | Low |
| Roditis [44] | 2023 | High | Low | UC | Low | Low | Low | Low |
| Savelli [45] | 2009 | Low | High | High | Low | Low | Low | Low |
| Savelli [46] | 2012 | Low | Low | High | UC | Low | Low | Low |
| Siddiqui [47] | 2021 | High | Low | UC | UC | Low | Low | Low |
| Sillou [48] | 2015 | High | Low | UC | UC | Low | Low | Low |
| Stoppa [49] | 2023 | Low | Low | High | Low | Low | Low | Low |
| Yap [16] | 2018 | Low | Low | High | Low | Low | Low | Low |
| Yin [50] | 2020 | High | Low | UC | Low | Low | Low | Low |
| Zhang [51] | 2019 | High | Low | UC | Low | Low | Low | Low |
Note—Determinations were made by consensus of two reviewers. Sel = selection, Ref = reference standard, UC = unclear.
| Modality, First Author [Reference] | Year | Department | No. of Patients | Sensitivity (%) | Specificity (%) |
|---|---|---|---|---|---|
| US | |||||
| Asgari [22] | 2022 | Gyn | 119 | 74.5a | 80.0a |
| Deslandes [27] | 2023 | Rad | 53 | 84.0b | 89.3b |
| Di Giovanni [28] | 2022 | Gyn | 4983 | 98.1c | 99.0c |
| Fratelli [29] | 2013 | Gyn | 420 | 53.6c | 94.63c |
| Goncalves [30] | 2021 | Rad | 120 | 88.5a | 94.23a |
| Guerriero [31] | 2008 | Gyn | 88 | 62.7c | 92.3c |
| Holland [33] | 2013 | Gyn | 198 | 52.2c | 98.7c |
| Hudelist [34] | 2011 | Gyn | 129 | 78.8c | 84.2c |
| Kamkarfar [35] | 2022 | Gyn | 80 | 71.0b | 96.4b |
| Padmehr [40] | 2023 | Gyn | 170 | 58.8a | 67.8a |
| Pateman [41] | 2015 | Gyn | 166 | 92.3b | 100.0b |
| Pattanasri [42] | 2020 | Gyn | 119 | 49.1c | 88.2c |
| Piketty [43] | 2009 | Gyn | 134 | 90.7b | 96.5b |
| Savelli [45] | 2009 | Gyn | 490 | 44.0b | 100.0b |
| Savelli [46] | 2012 | Gyn | 381 | 64.7 (88/136)b | 96.3 (236/245)b |
| Yin [50] | 2020 | Rad | 198 | 85.9c | 90.8c |
| Zhang [51] | 2019 | Rad | 118 | 95.3b | 90.9b |
| MRI | |||||
| Bazot [24] | 2012 | Rad | 83 | 83.3b | 98.6b |
| Chamié [26] | 2009 | Rad | 92 | 79.6c | 93.7c |
| Krüger [36] | 2013 | Rad | 152 | 78.0c | 79.2c |
| Manganaro [37] | 2012 | Rad | 46 | 97.0b | 100.0b |
| Mangler [38] | 2013 | Gyn | 79 | 41.0b | 83.0b |
| Manti [39] | 2022 | Rad | 72 | 86.9a | 96.0a |
| Siddiqui [47] | 2021 | Rad | 170 | 86.7 (85/98)b | 81.9 (59/72)b |
| Sillou [48] | 2015 | Rad | 35 | 91.022b | 59.0b |
| Stoppa [49] | 2023 | Rad | 77 | 80.0b | 35.0b |
| Yap [16] | 2018 | Rad | 37 | 76.9 (103/134)b | 98.5 (451/458)b |
| US and MRI | |||||
| Alborzi [21] | 2018 | Gyn | 317 | ||
| US | 83.3 (210/252)b | 46.1 (30/65)b | |||
| MRI | 90.4b | 66.1b | |||
| Alborzi [20] | 2023 | Gyn | 555 | ||
| US | 56.9a | 84.9a | |||
| MRI | 47.4a | 73.7a | |||
| Bartlett [23] | 2020 | Rad | 83 | ||
| US | 22b | — | |||
| MRI | 61b | — | |||
| Bazot [25] | 2009 | Rad | 92 | ||
| US | 74.3c | 187.9c | |||
| MRI | 82.9c | 90.3c | |||
| Hernández Gutiérrez [32] | 2019 | Gyn | 48 | ||
| US | 62.0a | 80.3a | |||
| MRI | 57.2a | 80.8a | |||
| Roditis [44] | 2023 | Rad | 178 | ||
| US | 69.7c | 91.3c | |||
| MRI | 56.6c | 64.1c | |||
| Weighted mean | |||||
| US studies | |||||
| All | 82.9c | 94.2c | |||
| Excluding outlierd | 65.1c | 88.5c | |||
| MRI studies | 69.0c | 76.1c |
Note—Dash (—) indicates value could not be calculated. Raw data for some performance measures are shown in parentheses. US = ultrasound, Gyn = gynecology, Rad = radiology.
| Studies Stratified by Imaging Modality, Performance Measure | Ovary | Bladder, VUP, Anterior CDS | Ureters | Pelvic SW, Ovarian Fossa | Vagina, RV Septum | PM, USLs, RC, Torus Uterinus | RS |
|---|---|---|---|---|---|---|---|
| No. of studies with US only | 9 | 9 | 4 | 3 | 7 | 13 | 11 |
| No. of studies with MRI only | 3 | 4 | 4 | 1 | 4 | 6 | 4 |
| No. of studies with US and MRI | 2 | 4 | 2 | 3 | 4 | 6 | 6 |
| All US studies | |||||||
| Sensitivity (%) | |||||||
| All studies | 77.5 (35.0–100.0) | 56.8 (0.0–100.0) | 64.7 (0.0–100.0) | 39.0 (3.8–84.0) | 60.8 (34.0–86.4) | 82.3 (1.8–98.1) | 73.7 (0.0–100.0) |
| Excluding outliera | 56.9 (1.8–96.5) | ||||||
| Specificity (%) | |||||||
| All studies | 84.4 (60.0–100.0) | 99.4 (0.0–100.0) | 99.3 (94.5–100.0) | 87.4 (74.7–100.0) | 95.5 (88.0–100.0) | 93.0 (0.5–99.0) | 92.5 (44.4–100.0) |
| Excluding outliera | 82.9 (0.5–99.2) | ||||||
| All MRI studies | |||||||
| Sensitivity (%) | 67.8 (56.9–97.0) | 73.0 (9.4–100.0) | 82.1 (0.0–100.0) | 63.6 (33.4–66.9) | 69.9 (41.0–100.0) | 60.0 (30.2–100.0) | 68.6 (13.0–100.0) |
| Specificity (%) | 83.2 (73.6–96.9) | 99.0 (94.7–100.0) | 97.5 (59.0–100.0) | 66.0 (45.7–98.1) | 89.3 (78.5–100.0) | 80.0 (35.0–100.0) | 87.4 (77.5–96.6) |
Note—Except where otherwise indicated, values are weighted means with the range in parentheses. US = ultrasound, VUP = vesicouterine pouch, CDS = cul-de-sac, SW = sidewall, RV = rectovaginal, PM = parametria, USL = uterosacral ligament, RC = retrocervical, RS = rectosigmoid.
| Studies Stratified by Imaging Modality, Performance Measure | East Asia and/or South Asia | Australia | Europe | West Asia | North America | South America |
|---|---|---|---|---|---|---|
| No. of studies with US only | 2 | 2 | 9 | 3 | 0 | 1 |
| No. of studies with MRI only | 1 | 1 | 7 | 0 | 0 | 1 |
| No. of studies with US and MRI | 0 | 0 | 3 | 2 | 1 | 0 |
| US studies | ||||||
| Sensitivity (%) | ||||||
| All | 89.4 (85.9–95.3) | 59.9 (49.1–84.0) | 86.4 (44.0–98.1) | 66.5 (56.9–83.3) | 8.1 | 88.5 |
| Excluding outliera | 61.5 (44.0–74.3) | |||||
| Specificity (%) | ||||||
| All | 90.8 (90.8–90.9) | 88.6 (88.2–89.3) | 97.9 (80.3–100.0) | 72.9 (46.1–96.4) | — | 94.2 |
| Excluding outliera | 95.4 (80.3–100.0) | |||||
| MRI studies | ||||||
| Sensitivity (%) | 86.7 | 76.9 | 72.5 (41.0–86.9) | 63.0 (47.4–90.4) | 41.2 | 64.2 |
| Specificity (%) | 81.9 | 98.5 | 77.3 (0.35–96.0) | 70.9 (66.1–73.7) | — | 97.0 |
Note—Except where otherwise indicated, values are weighted means with the range in parentheses. The location of the study was defined as the location of the first author's affiliation. Dash (—) indicates value could not be calculated. US = ultrasound.
Superficial Endometriosis
Endometriomas
DE
Evidence-Based Recommendations
Outstanding Issues That Warrant Research
Summary
Recommendations for Best Practices
Recommendations for Further Research
Acknowledgment
Footnotes
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- The Role of MRI in Diagnosis and Pre-Surgical Mapping of Endometriosis 2025
- Advancing endometriosis detection in daily practice: a deep learning-enhanced multi-sequence MRI analytical model 2025
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