Implementation of an endometriosis-specific MRI protocol reduces diagnostic laparoscopy rates and alters treatment paradigms in suspected deep endometriosis

OBJECTIVE: To evaluate the impact and diagnostic accuracy of an endometriosis-specific magnetic resonance imaging (MRI) protocol on the management of deep endometriosis (DIE). STUDY DESIGN: Retrospective cohort study at the Cleveland Clinic's Center for Pelvic Pain and Endometriosis, a tertiary care academic medical center. PARTICIPANTS: 444 new patients, aged ≥ 18, without prior diagnoses of endometriosis, gynecologic cancer, or pregnancy, who presented with pelvic pain suspicious for DIE between 2013 and 2020. INTERVENTION: Implementation of an endometriosis-specific MRI (EsMRI) protocol beginning January 1, 2017. MAIN OUTCOME MEASURES: The primary outcome was the number of diagnostic laparoscopies before and after EsMRI implementation. Secondary outcomes included frequency of medical vs. surgical management of endometriosis and the diagnostic accuracy of MRI, ultrasound, and laparoscopy. Of the three modalities studied, Laparoscopy demonstrated the highest sensitivity (95.9%, 95% CI: 92.0-99.8) and specificity (68.9%, 95% CI: 59.3-78.5). MRI had a sensitivity of 55.3% (95% CI: 41.1-69.5) and specificity of 78.6% (95% CI: 63.4-93.8). Transvaginal ultrasound had the lowest sensitivity at 21.3% (95% CI: 9.6-33.0) but the highest specificity at 82.9% (95% CI: 71.4-94.4). After EsMRI adoption, diagnostic laparoscopies decreased 2-fold. Medical management increased by 21.1%, while surgical-only and combined medical-surgical management decreased by 13.2% and 3.7%, respectively CONCLUSION: The introduction of an EsMRI protocol was associated with a reduced reliance on diagnostic laparoscopy and a shift toward medical management. Despite these changes, laparoscopy remains the most sensitive diagnostic tool for endometriosis.