Barriers and Enablers to the integration of Non-Invasive Diagnostic Approaches for patients with Endometriosis within clinical Diagnostic Pathways: A Scoping Review.

Introduction Endometriosis affects approximately 10% of women of reproductive age worldwide, with prevalence estimates ranging from 6% to 13%(Moradi et al., 2025; World Health Organization, 2025) . As a leading cause of chronic pelvic pain, the disorder significantly impairs daily functioning, mental health, and fertility; affected individuals demonstrate 3.3 fold higher odds of infertility compared to controls (Eisenberg et al., 2022; Wang et al., 2025). Beyond the profound physical and psychological toll, endometriosis imposes a substantial economic burden, with lifetime per-person losses estimated to exceed INT $1.9 million—driven largely by productivity loss (Armour et al., 2022; Tewhaiti-Smith & Armour, 2026). These findings underscore the urgency of timely management to mitigate long-term patient and systemic outcomes. In response to this clinical burden, there has been a paradigm shift toward non-invasive diagnostic approaches. Advanced imaging, such as specialist transvaginal ultrasound and high-resolution MRI, now demonstrates sensitivities and specificities of approximately 90% for deep endometriosis (Avery et al., 2024). Concurrently, biomarker research—including circulating inflammatory signatures and BCL6 expression—offers potential laboratory-based complements to imaging (Khoyloo et al., 2026). Guideline bodies, including NICE and ESHRE, increasingly recommend these non-invasive investigations as first-line tools, reserving laparoscopy for therapeutic purposes or inconclusive cases (Kennedy et al., 2005; Mondelaers, 2024). Despite technological advancements, diagnostic delays remain a persistent global challenge. Large-scale reviews report mean intervals of 6–8 years between symptom onset and confirmed diagnosis (Fryer et al., 2024, 2025). Delays are pervasive across varied healthcare systems, including cohorts in the United Kingdom, France, and the United States (De Corte et al., 2025; Hadfield et al., 1996) . While patient-level factors like pain normalization contribute to these delays, provider-level barriers—such as insufficient training, lack of standardized reporting, and persistent perceptions that laparoscopy is required for definitive diagnosis—frequently inhibit the transition from guideline recommendation to real-world practice (Condous et al., 2024; Nisenblat et al., n.d.). While individual diagnostic modalities have been extensively researched, there is limited synthesis regarding the integration of these tools into clinical pathways. Broader organisational and systemic factors—such as equipment availability, clinician training, medico-legal concerns, and geographic access—create a complex landscape of barriers and enablers (VanBuren et al., 2024; Young et al., 2024). Although implementation science frameworks like NASSS and CFIR have been applied to other healthcare innovations (Abell et al., 2023; Meunier et al., 2023), no comprehensive synthesis has specifically examined the determinants influencing the integration of non-invasive endometriosis diagnostics into routine care. The evidence base in this field is highly heterogeneous, encompassing qualitative patient experience studies, quantitative diagnostic accuracy trials, clinical guidelines, and policy literature. Traditional systematic reviews focused on narrowly defined interventions are unsuitable for this diverse, emerging field. A scoping review is therefore the appropriate methodology to systematically map this broad range of evidence, clarify key concepts, identify systemic barriers, and highlight gaps in current research. Guided by the JBI methodology for scoping reviews (Campbell et al., 2023), this review aims to map the available evidence regarding the use and integration of non-invasive diagnostic approaches within clinical diagnostic pathways for endometriosis. Consequently, this review addresses the following research question: What evidence exists on the use and integration of non invasive techniques by healthcare professionals in the diagnostic process of endometriosis? A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews, Embase, and JBI Evidence Synthesis confirmed no current or underway reviews addressing this integration, further justifying the necessity of this work (Armour et al., 2022; Saunders & Horne, 2025).