Addendum to consensus opinion from the International Deep Endometriosis Analysis (IDEA) group: sonographic evaluation of superficial endometriosis

Abstract

Traditionally, laparoscopy was considered to be the gold standard for the examination of endometriotic lesions, because it allows their direct visualization. Several international and national guidelines have now shifted their focus to non-invasive imaging-based diagnosis of deep endometriosis in preference to surgery, while laparoscopy is used to diagnose superficial endometriosis in patients with painful symptoms and negative ultrasound and/or magnetic resonance imaging findings for ovarian or deep endometriosis. In recent years, however, the role of gynecological ultrasound in the diagnosis of superficial endometriosis has been studied more extensively. The purpose of this addendum to the International Deep Endometriosis Analysis consensus opinion is to describe a standardized ultrasound protocol for the diagnosis of superficial endometriosis and to highlight the sonographic characteristics of these lesions. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Figure 1

(a) Appearance of superficial endometriosis at laparoscopy (based on Van Langendonckt et al. ¹⁵ ) and (b) corresponding ultrasonographic findings (based on Pedrassani et al., Leonardi et al. and Bailey et al. ²⁵ ).

Figure 2

Velamentous (filmy) adhesions at laparoscopy (a) and on ultrasound (b, arrows).

Figure 3

Summary of ultrasonographic findings associated with the presence of superficial endometriosis. Findings may appear in isolation (a,b,c) or in combination (d), and different lesions may show different associated findings within the same patient.

Figure 4

Examples of the ultrasound appearance of superficial endometriosis: (a) clustered linear cysts (arrows) with a hyperechogenic focus; (b) clustered tiny cyst (yellow circle and arrow) and two solitary cysts (arrows); (c) clustered tiny cysts with a honeycomb appearance; (d) solitary cyst (vesicle) (arrow); (e) clustered tiny cysts with a linear appearance (yellow circle and arrows), solitary tiny cyst (red circle and arrow) and solitary tiny cyst in a peritoneal small pocket (blue circle and arrow); (f) clustered tiny cysts with a honeycomb appearance (yellow circle and arrows) and solitary tiny cyst (red circle and arrow); (g) clustered tiny cysts with a hypoechogenic associated lesion (yellow circle and arrow), solitary cyst with a hyperechogenic focus in a small peritoneal pocket (red circle and arrow) and clustered cysts with a honeycomb appearance (blue circle and arrow); (h) solitary tiny cyst with hypoechogenic associated lesion and hyperechogenic focus (yellow circle and arrow) and clustered tiny cysts (red circle and arrow); (i) clustered cysts with a honeycomb appearance (arrows). POD, pouch of Douglas.