Endometriosis Diagnosis Pathway — A Structured Approach

Our approach to diagnosis

Diagnosis at Balaji Horizon follows the ESHRE 2022 and ESGE consensus pathways. Each stage adds information and is only progressed to when clinically indicated. Critically, we integrate fertility goals, ovarian reserve assessment, and long-term disease management into the diagnostic plan from day one. Diagnosis is not separated from treatment planning — they are designed together so that no patient is asked to undergo two procedures when one, planned correctly, will do.

Stage 1 — Clinical suspicion

A structured symptom assessment, including a menstrual pain diary, cyclical bowel and bladder symptom review, dyspareunia history, fertility goals, and family history. Pain that interferes with daily life is the trigger to investigate further.

Stage 2 — Expert ultrasound (ISUOG IDEA protocol)

Far more sensitive than routine pelvic ultrasound. The IDEA protocol systematically evaluates endometriomas, deep infiltrating disease in the posterior compartment, sliding-sign assessment for pouch of Douglas obliteration, ureteric involvement, and bowel involvement. Operator-dependent — done by clinicians with specific endometriosis ultrasound training.

Stage 3 — MRI mapping

Reserved for cases with suspected deep infiltrating disease or where surgical planning needs additional anatomical detail. MRI clarifies bowel, bladder, ureter, and rectovaginal involvement before any surgery is offered. For complex DIE cases, MRI is part of multidisciplinary planning with colorectal or urological colleagues.

Stage 4 — Diagnostic laparoscopy

No longer the default first step. Reserved for cases where imaging is inconclusive, where surgery is already planned for pain or fertility, or where excision is anticipated. Where surgery is required, we plan the procedure as a definitive operation — not as a separate diagnostic step followed later by a second therapeutic operation. ESHRE explicitly recommends this combined approach.

Why this matters

For decades, the conventional pathway was “wait until pain is intolerable, then do a diagnostic laparoscopy.” That pathway delayed diagnosis by years, exposed patients to unnecessary surgery, and frequently missed deep infiltrating disease that requires specialist surgical planning. The modern pathway flips the sequence — non-invasive expert imaging first, surgery only when justified and ideally with definitive intent. The result is faster diagnosis and fewer operations per patient.

Diagnostic tools and pathway pages

Guidelines we follow

• ESHRE 2022 Guideline on Endometriosis — diagnostic pathway
• ESGE consensus on diagnostic imaging in endometriosis
• ISUOG-IDEA consensus protocol
• AAGL clinical guidelines on diagnosis

Where this fits

Once diagnosis is established, see treatment options and endometriosis types. For fertility-focused diagnostic considerations, see endometriosis and fertility.

Dr Priyadatt Patel

Endometriosis & Advanced Laparoscopic Surgeon

Dr Patel leads endometriosis diagnosis and surgery at Balaji Horizon with an evidence-based, ovarian-sparing philosophy aligned to ESHRE and ESGE — integrating pain, fertility and long-term disease control into a single plan, rather than treating the disease in isolation.