For many years, the diagnosis of endometriosis was associated with surgery.
A patient had intense cramps, pain during sexual intercourse, bowel changes or difficulty getting pregnant. The symptoms raised suspicion, but confirmation was often linked to seeing the lesions during laparoscopy and analyzing the tissue removed.
That way of diagnosing endometriosis has changed.
Today, surgery is not indicated solely to find out whether a patient has the disease. Investigation is guided by the clinical history, physical examination and specialized imaging exams. Combining these pieces of information makes it possible to establish the diagnosis and define management in the vast majority of cases.
Surgery may be part of treatment when there is a concrete therapeutic indication, such as organ involvement, relevant anatomical changes or symptoms that have not responded to clinical strategies. In those situations, the procedure is not performed to look for endometriosis, but to treat a disease that has already been investigated and mapped.
Surgery was once considered the main way to confirm the disease
Endometriosis can present in very different ways. Some lesions are superficial and difficult to identify on imaging. Others involve the ovaries, bowel, bladder, ureters or deep areas of the pelvis.
For a long time, imaging resources did not allow these changes to be mapped with the precision available today. When symptoms suggested the disease, laparoscopy was performed to look directly at the pelvis, identify possible lesions and remove material for analysis.
That surgery had an essentially diagnostic purpose. The issue is that laparoscopy, although minimally invasive, is still a surgical procedure. It involves anesthesia, recovery and costs. In addition, not every patient with symptoms of endometriosis needs surgical treatment.
If a patient does not need surgery to be treated, why would it be necessary to operate only to find out whether the disease exists?
What changed in the diagnosis of endometriosis?
The change did not happen because of a single exam, but one of the main milestones occurred in 2007 with the development of a transvaginal ultrasound protocol with bowel preparation by Dr. Maurício Simões Abrão and Dr. Manoel Orlando Gonçalves.
The protocol made it possible to systematically assess not only the presence of lesions, but also their location, extent and relationship with structures such as the bowel, ovaries, bladder and deep pelvic areas.
The study published at that time showed high accuracy for identifying deep endometriosis, especially lesions in the rectosigmoid and retrocervical region. Based on those results, the protocol began to be adopted and replicated by specialized centres in Brazil and other countries.
This advance helped change the role of imaging. Ultrasound was no longer used only to look for ovarian cysts and began to function as a tool for diagnosis and mapping of endometriosis.
When performed by trained professionals, it can identify involved areas in advance, guide treatment choices and, when surgery is indicated, help plan the procedure and the necessary team.
This evolution, together with the value given to symptoms, clinical history and physical examination, made it possible to establish the diagnosis and define management without resorting to surgery for exclusively diagnostic purposes.
The historical contribution is documented in the prospective study published by Abrão and collaborators in 2007 and later incorporated into the FEBRASGO Endometriosis Manual.
Today, investigation can begin long before any surgical decision. A patient does not need to wait for the disease to be seen during an operation for her symptoms to be considered relevant.
Investigation begins with clinical suspicion
Before talking about confirmation, there is a fundamental step: recognizing that the symptoms may be related to endometriosis. No isolated symptom confirms the disease. What draws attention is the pattern they form, their progression and their relationship with the menstrual cycle.
- Disabling menstrual cramps
- Deep pain during sexual intercourse
- Pelvic pain outside menstruation
- Pain when having a bowel movement or urinating during menstruation
- Cyclical bowel changes
- Difficulty getting pregnant
- Symptoms that interfere with work, studies or routine
What does a clinical diagnosis of endometriosis mean?
A clinical diagnosis is built from the patient's history, symptoms, physical examination and assessment of other possible causes. In some situations, this set of findings produces a consistent suspicion that allows the physician and patient to discuss treatment and follow-up, even without surgical confirmation.
This may be called a clinical or presumed diagnosis. Presumed does not mean the symptoms are being treated as an unfounded assumption. It means the conclusion was built without surgical visualization and without histological analysis of a lesion.
What is the role of imaging exams?
Specialized transvaginal ultrasound and MRI can look for changes compatible with endometriosis and assess their location and extent. When performed by experienced professionals, they help identify endometriomas, deep nodules and possible involvement of the bowel, bladder and ureters.
The exam is no longer just an attempt to find endometriosis; it becomes part of management planning: which organs may be involved, whether clinical follow-up is possible and whether a potential surgery would require a multidisciplinary team.
Does a normal exam rule out endometriosis?
Not necessarily. Some forms of the disease, especially superficial lesions, may not be identified on imaging. A normal result should not automatically be interpreted as proof that the patient does not have endometriosis.
In this situation, it is necessary to assess whether the exam was performed with an adequate protocol, whether it was interpreted by an experienced professional, whether the symptoms form a suggestive pattern and whether other diagnoses are possible. A negative exam does not end the investigation, but it also cannot confirm by itself that endometriosis is present.
What is the difference between diagnostic and therapeutic surgery?
Diagnostic surgery is performed mainly to look for the disease and clarify the diagnosis. Therapeutic surgery is planned to excise lesions that have already been identified or are strongly suspected, considering symptoms, exams, involved organs and the patient's goals.
When surgery is indicated, ideally the operation should not be merely an exploration of the pelvis. The team needs to be prepared to treat what has already been mapped, within what has been discussed and authorized by the patient.
When is it possible to start treatment without surgery?
Clinical treatment can be considered when clinical assessment and specialized imaging indicate endometriosis, there are no signs of involvement that require surgical intervention and the patient's goals allow this strategy.
- Hormonal medications
- Pain relievers or anti-inflammatory medication
- Specialized pain management
- Pelvic floor physiotherapy
- Reproductive assessment when there is a desire to become pregnant
- Clinical monitoring and, when necessary, imaging follow-up
Removing the word “possible” makes clear that, in Dr. Maurício's approach, clinical treatment begins after endometriosis is confirmed by imaging.
Receiving the diagnosis does not mean needing surgery
The presence or suspicion of endometriosis does not automatically determine treatment. The decision considers the intensity and behaviour of symptoms, impact on quality of life, lesion location, organ involvement, response to treatments, fertility, ovarian reserve and the patient's preferences.
Frequently asked questions about diagnosing endometriosis without surgery
Can endometriosis be diagnosed without surgery?
Yes. Today, the diagnosis is established through clinical assessment combined with specialized imaging exams. Surgery is not indicated solely to find out whether a patient has endometriosis.
Is laparoscopy still used to diagnose endometriosis?
Laparoscopy is not indicated for exclusively diagnostic purposes. Surgery is considered when there is a concrete therapeutic indication and the disease has already been investigated and mapped.
Does a normal ultrasound rule out endometriosis?
A normal ultrasound does not confirm the presence of the disease and must be interpreted within the clinical context. When symptoms persist, it may be necessary to review the quality and protocol of the exam, seek specialized assessment and investigate other possible causes.
Which exam can identify endometriosis?
The main exams are specialized transvaginal ultrasound, performed with a protocol for endometriosis mapping, and pelvic MRI. The choice depends on the patient's characteristics and the structures that need to be assessed.
Can treatment begin without biopsy confirmation?
Yes. Clinical treatment can begin when the evaluation and specialized imaging exam indicate endometriosis, without the need for prior histological confirmation.
What is the difference between diagnostic and therapeutic surgery?
Diagnostic surgery would aim to look for or confirm the presence of the disease. This is not Dr. Maurício's approach. Therapeutic surgery is planned to treat endometriosis that has already been diagnosed and mapped by imaging.
When can laparoscopy be indicated?
Laparoscopy may be indicated for therapeutic purposes, for example when organs are involved, relevant anatomical changes are present or the benefits of intervention outweigh its risks. It is not performed only to confirm the diagnosis.
Is biopsy necessary to diagnose endometriosis?
No. When surgery is performed for therapeutic reasons, the removed tissue may be sent for histological analysis. This complements the evaluation of the removed material, but it is not necessary to establish the diagnosis beforehand or to begin treatment.