AFIP ARCHIVES 193

From the Archives of the AFIP

Endometriosis: Radiologic-Pathologic
Correlation1

CME FEATURE
Paula J. Woodward, MD • Roya Sohaey, MD • Thomas P. Mezzetti, Jr,
See accompanying
LCDR, USNR, MC
test at http://
www.rsna.org
/education Endometriosis is an important gynecologic disorder primarily affecting
/rg_cme.html
women during their reproductive years. Pathologically, it is the result
of functional endometrium located outside the uterus. It may vary
LEARNING
OBJECTIVES
from microscopic endometriotic implants to large cysts (endometrio-
FOR TEST 5 mas). The physical manifestations are protean, with some patients be-
After reading this ing asymptomatic and others having disabling pelvic pain, infertility, or
article and taking
the test, the reader
adnexal masses. Symptoms do not necessarily correlate with the sever-
will be able to: ity of the disease. Ultrasonographic (US) features are variable and can
■ Outline the pro- mimic those of other benign and malignant ovarian lesions. Low-level
posed mechanisms internal echoes and echogenic wall foci are more specific US features
of pathogenesis of
endometriosis and for endometriomas. Magnetic resonance imaging improves diagnostic
how they relate to accuracy, with endometriotic cysts typically appearing with high signal
the distribution of
disease. intensity on T1-weighted images and demonstrating “shading” on T2-
■ Identify which im- weighted images. The ovaries are the most common sites affected, but
aging features are endometriosis can also involve the gastrointestinal tract, urinary tract,
more specific for en-
dometriosis and help chest, and soft tissues. Small implants and adhesions are not well eval-
to distinguish it from uated radiologically; therefore, laparoscopy remains the standard of ref-
other adnexal masses.
■ Describe the un-
erence for diagnosis and staging. Both medical and surgical treatment
usual manifestations options are available depending on the patient’s specific case.
and complications
that can be seen with
endometriosis.

Index term: Endometriosis, 70.318, 80.3192

RadioGraphics 2001; 21:193–216

1From the Departments of Radiologic Pathology (P.J.W.) and Gynecologic and Breast Pathology (T.P.M.), Armed Forces Institute of Pathology,

Bldg 54, Room M-121, Washington, DC 20306-6000; the Department of Radiology, Oregon Health Sciences University, Portland (R.S.); and
the Department of Radiology, University of Utah, Salt Lake City (P.J.W.). Received July 7, 2000; revision requested July 24; revision received
August 1; accepted August 3. Address correspondence to P.J.W. (e-mail: woodwardp@afip.osd.mil).

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official nor as representing the
views of the Departments of the Navy or Defense.
©RSNA, 2001
194 January-February 2001 RG ■ Volume 21 • Number 1

Introduction Epidemiology
Endometriosis is classically defined as the pres- Endometriosis is found predominantly in women
ence of functional endometrial glands and stroma of childbearing age. The mean age at diagnosis is
outside the uterine cavity (ectopic as opposed to 25–29 years, but it is often greater in women who
normally located or eutopic endometrium). In present with infertility rather than pelvic pain (1).
older literature, endometriosis was further classi- Endometriosis is not uncommon among adoles-
fied as endometriosis interna and endometriosis cents. Approximately half of women under 20
externa. Endometriosis interna referred to en- years of age who have chronic pelvic pain or dys-
dometrial tissue within the uterine musculature, pareunia have the disease (2,3). Obstructive
and endometriosis externa referred to endome- müllerian duct anomalies of the cervix or vagina
trial tissue in all other sites. Currently, the term account for most cases of endometriosis in girls
adenomyosis has replaced endometriosis interna. under the age of 17 years (4). About 5% of endo-
Adenomyosis is considered a distinct and differ- metriosis cases are seen in postmenopausal
ent clinical entity because its pathogenesis, symp- women, and exogenous estrogen replacement
toms, and epidemiology differ from those of en- therapy is suggested to play a role (5). In rare
dometriosis. Endometriosis externa is now simply cases, men undergoing long-term estrogen thera-
called endometriosis and is the condition reviewed py may be affected (5).
in this article. The prevalence of endometriosis is difficult to
Endometriosis is a common and important determine accurately. Laparoscopy or surgery is
clinical problem of women, predominantly those required for the definitive diagnosis. Endometri-
in the reproductive age group. At pathologic osis has been reported in 4.1% of asymptomatic
analysis, it can vary from microscopic foci to large, women undergoing laparoscopy for tubal ligation.
grossly visible endometriotic cysts (endometrio- However, in the same study, 20% of women un-
mas). Radiologists are often involved in the diag- dergoing laparoscopic investigation for infertility
nosis and work-up of this disease in one of two and 24% of women with pelvic pain had endo-
scenarios: They are asked to exclude endometri- metriosis (6). Overall prevalence, including both
osis in a woman with pelvic pain or infertility or symptomatic and asymptomatic women, is esti-
they are considering endometriosis in the differ- mated to be 5%–10% (7,8).
ential diagnosis of an adnexal mass. When social and economic factors are accounted
Radiologists often use the terms endometriosis for, the prevalence of endometriosis is the same in
and endometriomas interchangeably. It is important women of different races (9,10). In a recent study,
to remember, however, that endometriomas are investigators compared menstrual characteristics
only a part of the disease process, which also in- that would increase peritoneal exposure to men-
cludes endometriotic implants and adhesions. All of strual fluid with the risk of developing endometri-
these features are important in the staging of endo- osis. The three characteristics studied were age of
metriosis, and normal results from an imaging pro- menarche, duration of menstrual flow, and men-
cedure do not rule out the presence of disease. strual cycle length. The only menstrual characteris-
To help radiologists better understand this tic that was significantly associated with endometri-
disease process, we review its epidemiology, osis was a menstrual cycle length of less than 28
pathogenesis, staging, and clinical features. Al- days (11). An increased prevalence of endometri-
though its imaging characteristics overlap with osis in families has been observed, and therefore a
those of other adnexal masses, those features genetic effect has been suggested (12).
more specific to endometriosis are discussed,
along with the strengths and weaknesses of the Pathogenesis
various imaging modalities. Endometriosis can Endometriosis is a complex disorder, and its
also occur in nongynecologic sites. A knowledge causes are probably multifactorial. Three theories
of these locations, their clinical manifestations, of histogenesis have been proposed: (a) metastat-
and radiologic appearances will aid radiologists in ic theory (retrograde menstrual implantation,
considering endometriosis in the differential diag- vascular and lymphatic spread, and intraopera-
nosis. Atypical manifestations of endometriosis, tive implantation), (b) metaplastic theory, and
complications, and treatment are also discussed. (c) induction theory (Fig 1). In addition, re-
searchers are presently investigating the role of
growth factors, immunity, and other mechanisms
RG ■ Volume 21 • Number 1 Woodward et al 195

1. 2.
Figures 1, 2. (1) Drawing depicts the potential mechanisms of endometriosis pathogenesis, including retrograde
menstruation (a), lymphatic spread (b), hematogenous spread (c), and coelomic metaplasia (d). Induction of undif-
ferentiated mesenchyma by unidentified endometrial substances is also theorized. (2) Drawing illustrates common
sites of endometriosis.

that may contribute to the development of this A second theory of histogenesis is that of meta-
disorder. plastic differentiation of serosal surfaces (coelomic
The most widely accepted theory is that endo- epithelium) or müllerian remnant tissue. Both
metriosis results from metastatic implantation endometrial and peritoneal cells derive from the
from retrograde menstruation (7,13,14). The coelomic wall–epithelium. The theory suggests
theory assumes transportation of endometrial tis- the possibility of peritoneal cells differentiating
sue from the uterus in a retrograde fashion into into functioning endometrial cells. The strongest
the peritoneal cavity. The endometrial cells re- evidence for this theory is the demonstration of
main viable and implant on serosal surfaces out- endometriosis in women lacking functional
side the uterus. The occurrence of retrograde eutopic endometrium (eg, those with Turner
menstruation has been documented with diag- syndrome, gonadal dysgenesis, uterine agenesis)
nostic laparoscopy and studies of peritoneal di- and in men (22). In the rare cases of endometri-
alysis fluid. Up to 90% of women have bloody osis occurring in men, they have usually received
peritoneal fluid during the perimenstrual period high doses of estrogen, which is sometimes done
(15–17). Investigators have shown the in vitro in the treatment of prostate carcinoma (7,23,24).
growth potential of shed endometrium and have In these men, the cause is possibly hyperplasia
demonstrated viable endometrial cells in perito- and spread of endometrial tissue from the pros-
neal fluid (7,18,19). Further evidence for this tatic utricle (a müllerian remnant) (7).
theory is suggested by the anatomic pattern of A third theory, the induction theory of endo-
the disease within the dependent areas of the pel- metriosis, is a combination of the first two. It
vis (Fig 2) (20). Endometriosis is also seen with suggests that shed endometrium releases sub-
greater frequency in women with excessive retro- stances that induce undifferentiated mesenchyma
grade flow due to obstructive anomalies of mül- to form endometriotic tissue (7). These sub-
lerian duct development (21). Other possible stances have not been identified, but animal re-
routes of metastatic spread include transport of search has shown the formation of endometrial
endometrial cells to distant sites via the blood glands (but not stroma) when experiments have
stream or lymphatic channels or iatrogenically been performed to test this theory (7,25).
during surgery or needle biopsy (22).
196 January-February 2001 RG ■ Volume 21 • Number 1

Figure 4. Intraoperative view shows the surgeon re-

Figure 3. Laparoscopic view shows endometriotic tracting the uterus to reveal three dark-brown endome-
implants, which range from pale yellow to red. Arrow triotic implants in the cul-de-sac (arrows). These le-
points to a very small implant, which could be missed sions are mature endometriotic implants.
at laparoscopy.

Table 1
Regardless of which theory is correct, other Most Common Sites for Endometriotic Im-
factors probably play a role in the occurrence of plants and Adhesions
endometriosis, since all women are not equally
Implants Adhesions
susceptible. Impairment of the immune response
Location (%) (%)
to remove peritoneal menstrual debris has been
suggested as an additional factor. Women with Ovaries 76 39
endometriosis have been found to have abnor- Anterior and
malities of T-cell–mediated cytotoxicity, natural posterior cul-de-sac 69 13
killer cell activity, B-cell function, and comple- Posterior broad ligament 47 43
Uterosacral ligament 36 7
ment deposition (26,27). The role of growth fac-
Uterus 11 3
tors and factors critical to cell implantation are
Fallopian tubes 6 26
also receiving attention (7). Sigmoid colon 4 12
Finally, the biologic behavior of ectopic en- Ureter 3 2
dometrial glands is variable and adds to the com- Small intestine 0.5 3
plexity of the disease. Ectopic endometriotic im-
plants generally respond to circulating hormones Source.—Adapted from reference 20.
in the same manner as eutopic endometrium
(though to a lesser degree). Estrogen stimulates
glandular growth, whereas progesterone inhibits
it. However, ectopic endometrium often behaves patches (usually less than 2 cm). The amount of
unpredictably, which leads to difficulties in diag- pigment in the implant appears to increase with
nosis and treatment (22). the age of the lesion. They may initially be un-
pigmented or appear as white, yellow, or red fo-
Pathologic Features ci, which progress to a more mature-appearing
Gross pathologic findings of endometriosis de- blue or brown lesion (Figs 3, 4) (22,28). These
pend on the duration of the disease and depth of brown, ecchymotic areas have been described as
penetration of the lesions. Endometriotic im- “powder burns.” Implants may change in appear-
plants vary from punctate foci to small stellate ance during the menstrual cycle, becoming more
swollen and congested during menses and bleed-
ing in some cases. These mature endometriotic
foci initiate an inflammatory response, with areas
RG ■ Volume 21 • Number 1 Woodward et al 197

a. b.
Figure 5. Left ovarian endometrioma in a 30-year-old woman. (a) Transabdominal US scan shows a hypoechoic
mass replacing the left ovary (arrows). Note the thickened wall. (b) Photograph of the gross specimen (external sur-
face on the left and internal surface on the right) reveals stellate patches of hemorrhage on the external surface (solid
arrows) and a thick-walled, dark, irregular internal cyst lining. A portion of the fallopian tube was adherent to the
endometrioma (open arrow). Scale is in centimeters.

a. b.
Figure 6. Right ovarian endometrioma in a 25-year-old woman. (a) Transvaginal US scan shows an echogenic
ovarian cyst filled with low-level echoes. (b) Photograph of the resected cyst, which has been opened, shows dark-
brown, viscous blood products. This appearance has been called a chocolate cyst. Multiple irregular hemorrhagic
foci are seen on the external surface of the cyst.

of organizing hemorrhage, fibrosis, and adhesion sue. Cyst walls are generally thick and fibrotic and
formation. Extensive adhesions can distort the commonly have areas of discoloration and dense
normal pelvic anatomy and obliterate the pouch fibrous adhesions. The cyst lining can vary from
of Douglas (22,28–30). The most common site smooth and pale to shaggy and brown (Fig 5).
of involvement is the ovary, but virtually all pel- Although cyst contents can be watery, they more
vic organs can be affected by the disease (Table typically are composed of thick, dark, degener-
1) (20). ated blood products. This appearance has been
Endometriotic cysts (endometriomas) gener- called “chocolate cyst” (Fig 6). Endometriomas
ally occur within the ovaries and are the result of
repeated cyclic hemorrhage within a deep implant.
They may completely replace normal ovarian tis-
198 January-February 2001 RG ■ Volume 21 • Number 1

a. b.
Figure 7. Microscopic appearance of an endometriotic implant. (a) Medium-power photomicrograph (original
magnification, ´4; hematoxylin-eosin stain) shows endometriotic glands and stroma (center). The endometriotic tissue
is surrounded by fibrosis (arrows) as well as degraded blood products and inflammatory debris (*). (b) High-power
photomicrograph (original magnification, ´80; hematoxylin-eosin stain) shows dark-brown particles of hemosiderin
or hemofuscin (straight arrows) and scattered red blood cells (curved arrows). A layer of endometriotic glands is
partially visible in the lower left corner.

are bilateral in up to half of the cases and may be (22,30). In rare cases, endometriosis may lack
large, although they seldom exceed 15 cm in di- glands (stromal endometriosis) (22).
ameter (22,29). Large lesions and lesions with
wall nodularity should be carefully sampled to Clinical Characteristics
rule out malignancy. Symptoms associated with endometriosis include
At microscopic analysis, endometriosis is com- infertility and pelvic pain. These nonspecific
posed of endometrial glands, stroma, and occa- symptoms can accompany a wide variety of disor-
sionally smooth muscle fibers. As with eutopic ders and are not pathognomonic for endometri-
endometrium, the ectopic endometrial foci re- osis. Unusual symptoms linked to atypical loca-
spond to circulating hormones and may show tion of disease can also occur. The extent of en-
secretory changes during the second half of the dometriosis does not always correlate with the
menstrual cycle and stromal decidualization dur- severity of symptoms, which further complicates
ing pregnancy (28). Hemorrhage within these the diagnosis. However, endometriosis should be
foci results in an inflammatory response, with in- considered in any woman of reproductive age with
filtration of histiocytes that become pigment pelvic pain or infertility.
laden with hemosiderin and hemofuscin (Fig 7) Infertility, with or without pelvic pain, may be
the presenting complaint in women with endo-
metriosis. It is estimated that 30%–50% of women
RG ■ Volume 21 • Number 1 Woodward et al 199

with endometriosis are infertile, and 20% of in- ment. Pelvic organs may be fixed from adhesions,
fertile women have endometriosis (6,31). Al- with the uterus often fixed in a retroverted posi-
though the association between the two is well tion (7). The physical examination should be
established, the causal mechanism is debated. An performed during early menses because implants
acceptable explanation is that endometriomas are more likely to be large and tender at this time
and adhesions cause pelvic distortion, which in the cycle. However, most women with endo-
leads to impaired ability of the fallopian tubes to metriosis have normal or nonspecific results from
capture ovum (7,31). In cases in which minimal physical examinations, and laparoscopy is neces-
endometriosis is present, the clinician must de- sary for the definitive diagnosis (13).
cide if the finding is incidental. Some proposed Laparoscopy is the standard of reference in the
mechanisms for infertility in women with mini- diagnosis of endometriosis. Although histologic
mal disease include abnormalities related to au- analysis of biopsy specimens to confirm the diag-
toimmunity and peritoneal fluid factors (31). nosis is desirable, it is not necessary. Staging of
Pelvic pain is a frequent complaint from the disease can also be done during laparoscopy.
women with endometriosis. Common symptoms Endometriotic implants, endometriomas, and ad-
include dysmenorrhea, dyspareunia, chronic pel- hesions are the typical findings. Implants may
vic pain, back pain, and rectal discomfort (8). measure from a few millimeters to a few centime-
The pain is not always cyclic, and endometriosis ters and may be superficial or deep. Because
is present in approximately one-third of patients endometriotic implants can vary in appearance,
with chronic pelvic pain (31). the accuracy of diagnosis depends on the ability
Unusual symptoms may occur when endome- of the surgeon to recognize the disease (Figs 3,
triotic implants occur in atypical locations. In- 4) (8). A pattern of lesion maturity has also been
volvement of the gastrointestinal tract may mani- described, with subtle findings seen in young
fest with catamenial diarrhea, rectal bleeding, women and more characteristic features identi-
and constipation. Bladder involvement may re- fied in the same women a decade later (35).
sult in urgency, frequent urination, and hema- Endometriotic cysts may be seen, most com-
turia. Ureteral involvement may cause urinary monly involving the ovaries. Inflammatory re-
obstruction and flank pain. Pleuritic chest pain, sponse to active endometrial lesions can lead to
pneumothorax, pleural effusions, or cyclic he- fibrosis and adhesions. Severe adhesions may ac-
moptysis can occur with pulmonary involvement tually compartmentalize the pelvis and impede
(32). Cyclic headaches, seizures, and subarach- laparoscopic evaluation.
noid hemorrhage have been described with brain The most widely used staging system for en-
lesions (33,34). Cutaneous lesions may manifest dometriosis is the 1985 Revised Classification of
with catamenial bleeding and tenderness (31). Endometriosis published by the American Fertil-
ity Society (8,36). This system consists of three
components: evaluation of the endometrial im-
Diagnostic Evalu-
plants (location, size, and depth of penetration),
ation: Physical Examina- degree of cul-de-sac obliteration, and evaluation
tion, Laparoscopy, and Staging of adhesions (amount of surface area involvement
Physical findings for endometriosis are nonspe- and appearance) (Table 2). On the basis of their
cific. Localized tenderness along the uterosacral score, patients are categorized as having mini-
ligaments and the cul-de-sac is often present. mal, mild, moderate, or severe disease. Critics of
Thickened or nodular ligamental or rectovaginal staging note that the stage of disease does not
masses may be palpated. Adnexal tenderness or
masses may be found if there is ovarian involve-
200 January-February 2001 RG ■ Volume 21 • Number 1

Table 2
Endometriosis Staging System of the American Fertility Society

A. Endometrial Implants
Size
Location Depth of Penetration <1 cm 1–3 cm >3 cm
Peritoneum Superficial 1 2 4
Deep 2 4 6
Ovary Right superficial 1 2 4
Right deep 4 16 20
Left superficial 1 2 4
Left deep 4 16 20
B. Obliteration of the Posterior Cul-de-sac
Degree of Obliteration Score
Partial 4
Complete 40
C. Adhesions
Amount of Surface Involvement
< 1/3 1/3–2/3 > 2/3
Location Appearance Enclosure Enclosure Enclosure
Ovary Right filmy 1 2 4
Right dense 4 8 16
Left filmy 1 2 4
Left dense 4 8 16
Fallopian tube Right filmy 1 2 4
Right dense 4 8 16
Left filmy 1 2 4
Left dense 4 8 16
Note.—Stage I (minimal) = score 1-5, stage II (mild) = score 6-15, stage III (moderate) = score 16-40, stage
IV (severe) = score >40. From reference 36.

Radiologic
necessarily correlate with the severity of symp-
toms (7,13), and consistent treatment options
Evaluation of Endometriosis
based on stage of disease have not been estab- Not unexpectedly, radiologic evaluation of small
lished (7). Despite these limitations, staging is endometriotic implants is limited; therefore, the
thought to offer some standardization in stratify- radiologist’s role is generally to identify and eval-
ing disease severity and in assessing response to uate endometriotic cysts. Because symptoms are
therapy. variable, patients may be referred for a diverse ar-
ray of imaging studies, including excretory urog-
raphy, barium studies, and computed tomogra-
phy (CT). These techniques lack both sensitivity
RG ■ Volume 21 • Number 1 Woodward et al 201

a. b.
Figure 8. Diffuse endometriosis in a 27-year-old woman
with pelvic pain. (a) Transabdominal midline sagittal US
scan shows a complex cystic mass (white arrow) posterior
to the uterus (U) filling the cul-de-sac (black arrow, right
ovary). (b) Transvaginal US scan shows that the mass is
contiguous with the serosal surface of the right ovary (ar-
row). (c) Photograph of the resected specimen shows ex-
tensive fibrous tissue and cysts filled with hemorrhage (ar-
rows). This mass obliterated the cul-de-sac and was ad-
herent to both the right ovary and appendix. Scale is in
centimeters.

Ultrasonography
Both transvesicular and transvaginal US should
be performed. Cysts involving the ovaries should
be completely characterized, with attention given
to internal echogenicity, wall morphology, and
effects on surrounding organs. Because the cul-
c. de-sac is commonly involved, care should be
taken during scanning to evaluate this area com-
pletely (Fig 8).
and specificity, and a variety of nonspecific radio- Endometriomas can have a variety of US ap-
logic findings may be seen. Ultrasonography (US) pearances. The majority exhibit diffuse low-level
is the most common imaging modality used to internal echoes, with the “classic” endometrioma
evaluate suspected endometriosis. However, it is being described as a homogeneous, hypoechoic
applicable only to the evaluation of endometriotic focal lesion within the ovary (Figs 5, 6) (37–41).
cysts; detection of adhesions or implants with US In one recent study of 40 endometrial cysts, 95%
is only anecdotal. Magnetic resonance (MR) im- demonstrated this finding (37). In rare cases,
aging has proved to be a very useful and more spe- they may be anechoic, mimicking a functional
cific imaging technique and is often used as a ovarian cyst.
problem-solving tool.
202 January-February 2001 RG ■ Volume 21 • Number 1

a. b.
Figure 9. Endometrioma with thin septations in a 26-year-old woman. Sagittal (a) and transverse (b) transvaginal
US images show a cystic mass posterior to the uterus in the cul-de-sac. It is filled with low-level internal echoes and
has a thin septation within it (long arrow). Bright echogenic foci are seen within the cyst wall (short arrows).

a. b.
Figure 10. Endometrioma with thick septations in a 35-year-old woman. (a) Transvaginal US scan shows
thick septations (arrow) with areas of wall irregularity (arrowhead). (b) Photograph of the gross specimen
shows an irregular wall and septations (forceps). This appearance overlaps with that of a neoplasm. Scale is in
centimeters.

Endometriomas may be unilocular or mul- The US appearance of the endometrial cyst

tilocular. A multilocular-appearing endometrio- wall can be variable but deserves special atten-
ma may actually consist of multiple separate tion. Diffuse wall thickening, wall nodularity, and
cysts. Thin or thick septations may be present be- echogenic foci within the cyst wall have been ob-
tween these loculi. One study showed that in the served (37,39). Patel et al (37) found no diagnos-
absence of wall nodularity and in the presence of tic value in the assessment of wall thickness for
diffuse low-level echoes, a multiloculated mass differentiating between endometriomas and other
was 64 times more likely to be an endometrioma ovarian masses. In their study, 20% of endome-
(Fig 9) (37). In the absence of these features, triomas had solid-appearing wall nodularity, a
neoplasia cannot be excluded (Fig 10). feature that is classically associated with neopla-
sia (37).
RG ■ Volume 21 • Number 1 Woodward et al 203

12. 13.
Figures 12, 13. (12) Dermoid cyst. Transvaginal US scan demonstrates a cystic mass with an area of low-level
echoes that could be mistaken for an endometrioma. However, the lesion also has a well-defined area of increased
echogenicity (arrow), a finding that makes a dermoid cyst the more likely diagnosis. (13) Hemorrhagic cyst mimick-
ing an endometrioma. Transvaginal US scan shows a hypoechoic cystic lesion in the left ovary. The patient had pre-
sented with acute pain, a symptom that makes the diagnosis of a hemorrhagic cyst more likely. A 6-week follow-up
scan showed resolution.

omas. The finding was the highest single predic-

tor for endometrioma. Although the pathologic
basis of these echogenic foci has not been estab-
lished, it is postulated that they form as choles-
terol deposits accumulate in the endometriotic
cyst wall. The finding is reminiscent of choles-
terol deposits in the wall of a gallbladder with
adenomyomatosis (37,41).
Dermoid cysts, hemorrhagic cysts, and cystic
neoplasms can all overlap in their US appear-
ances with that of endometriomas and must be
considered in the differential diagnosis. However,
careful analysis of the US characteristics will help
narrow the differential possibilities. Dermoid cysts
typically have unique identifiers such as calcifica-
tion, fat-fluid levels, and hyperechoic areas (Fig
12). An acute hemorrhagic cyst can sometimes
Figure 11. Right ovarian endometrioma. Transvagi- be difficult to differentiate from an endometrioma
nal US scan reveals a cystic mass with echogenic foci (Fig 13). Patient history may be helpful, since the
(arrows) within its walls. symptoms accompanying hemorrhagic cysts are
often more acute than those that usually occur
with endometriosis. Hemorrhagic cysts will evolve
Echogenic wall foci differ from wall nodularity into more complex-appearing cysts, with clot re-
and are an important discriminating feature. traction and fibrin stranding, and generally re-
These deposits are more echogenic and smaller solve in 4–6 weeks. Fibrin strands can mimic the
than true wall nodules (Figs 9, 11). If not care- septations seen in an endometrioma, but they
fully searched for, these deposits may be missed. are generally thinner and are weaker reflectors
In the study performed by Patel et al (37), 35% compared with true septations (41). If the lesion
of endometriomas demonstrated hyperechoic
wall foci, compared with 6% of nonendometri-
204 January-February 2001 RG ■ Volume 21 • Number 1

resolves on a follow-up examination, an endome-

trioma is effectively ruled out. In addition to the
above characteristics, endometriomas are more of-
ten multiple or bilateral, compared with the other
benign lesions (Fig 14). If the cyst has soft-tissue
components, a neoplasm must be excluded.
In summary, the US features of endometriomas
are quite variable and sometimes mimic other be-
nign and malignant ovarian lesions. Diffuse low-
level internal echoes and echogenic wall foci are
more classic features. Endometriotic cysts may
have septations, thickened walls, and wall nodu-
larity. Because of this wide variability, endometri-
omas are considered by many to be the most dif-
ficult adnexal lesion to diagnose confidently with
US. Short-term follow-up US or MR imaging
can often help with making the diagnosis. Figure 14. Bilateral endometriomas. Transabdomi-
nal US scan demonstrates two large, homogeneous,
MR Imaging low-level echo masses posterior to the uterus. L = left,
As suggested, the confident US differentiation of R = right, U = uterus.
endometriotic cyst from other adnexal masses
may be difficult at times. MR imaging has been
shown to have greater specificity for the diagnosis tissue signal. Endometriomas have a relatively
of endometriomas than other noninvasive imag- homogeneous high signal intensity (similar to or
ing techniques (42–44). It affords a larger field of greater than that of fat) on T1-weighted images.
view than US, and the effect of adhesions on sur- With the high signal intensity of surrounding fat
rounding anatomic structures is better depicted. removed, lesion conspicuity is improved. Use of
Therefore, MR imaging can be a helpful adjunct this pulse sequence is important in the evaluation
for evaluation of adnexal masses. of endometriosis. It has been shown to improve
If available, MR imaging should be performed the sensitivity of MR imaging in the detection of
using a dedicated pelvic coil. These external small lesions and to increase its specificity, since
multicoil arrays provide a higher signal-to-noise fat-containing lesions such as dermoids are elimi-
ratio, which improves spatial resolution and en- nated from the differential diagnosis (45–49).
hances visualization of anatomic detail. Imaging Administration of gadolinium-based contrast
planes can include all three standard projections material is not particularly useful in the evalua-
(axial, sagittal, and coronal), with the sagittal tion of endometriomas. When used, the cyst wall
plane being particularly useful for evaluating the demonstrates a nonspecific, variable enhance-
cul-de-sac and rectum. ment pattern that does not differentiate it from
In addition to using routine T1-weighted and other benign and malignant processes (47,50). In
T2-weighted pulse sequences, a T1-weighted addition, a false-positive diagnosis may be made
fat-suppressed sequence should always be per- when normally enhancing parametrium is misin-
formed. Fat suppression narrows the dynamic terpreted as endometriotic foci (51). Use of gad-
signal range, thereby accentuating differences in olinium should be reserved for those cases in
which there is a concern for ovarian carcinoma.
RG ■ Volume 21 • Number 1 Woodward et al 205

a. b.
Figure 15. Bilateral endometriomas in a 27-year-old
woman. (a) Axial T1-weighted MR image shows bilat-
eral high-signal-intensity adnexal masses (solid arrows).
An intrauterine device is seen within the uterus (open
arrow). (b) On a T1-weighted fat-suppressed image,
these masses remain bright, a finding that effectively
rules out a diagnosis of dermoid cyst. (c) T2-weighted
image shows shading with mixed high and low signal
intensity in both lesions (arrows). Open arrow = in-
trauterine device.

mulating over months to years. These chronic le-

sions are very viscous, with extremely high con-
centrations of iron and protein. At these high
concentrations, protein cross-linking can occur,
c.
with a consequent decrease in T2-relaxation time.
All of these factors may contribute to shading (42,
52–54).
Lesions with degenerated blood products, in- Shading is present when a cyst that is hyperin-
cluding methemoglobin and concentrated pro- tense on a T1-weighted image becomes hypoin-
tein, appear with high-signal-intensity areas on tense on a T2-weighted image. Although the T2-
T1- and T2-weighted images. A common and weighted image often shows mixed high and low
important feature of an endometrioma is “shad- signal intensity, findings can be quite variable.
ing” (ie, loss of signal within the lesion), which Shading can range from faint, dependent layering
can be seen on T2-weighted images (42,46). to complete signal void, reflecting the concentra-
This shading reflects the chronic nature of an en- tion of blood products (42,53) (Figs 15, 16). He-
dometrioma and helps differentiate it from other mosiderin-laden macrophages combined with the
blood-containing lesions. Blood products within
these cysts are the result of cyclic bleeding accu-
206 January-February 2001 RG ■ Volume 21 • Number 1

a. b.
Figure 16. Bilateral endometriomas in a 46-year-old woman. (a) Axial T1-weighted MR image shows a unilocular
high-signal-intensity mass on the right and a multilocular high-signal-intensity mass on the left (arrows). (b) T2-
weighted image shows that the right-sided mass remains high in signal intensity (short arrow), whereas the one on the
left shows shading with marked signal loss (long arrows). The variable appearance of these lesions is thought to re-
flect the concentration of blood products.

fibrous nature of the cyst wall give it a low-sig- images, but the signal is considerably less intense
nal-intensity appearance on both T1- and T2- than that of fat or blood (55). The most prob-
weighted images. lematic lesions to differentiate are hemorrhagic
Looking at both the multiplicity and signal in- corpus luteum cysts, whose MR imaging appear-
tensity of lesions, Togashi et al (42) found that a ance can be similar to that of endometriomas.
“definitive” diagnosis of an endometrioma was Hemorrhagic cysts are usually unilocular as op-
made when a cyst was hyperintense on T1- posed to endometriomas, which are frequently
weighted images and shading was observed on multilocular and bilateral. In addition, hemor-
T2-weighted images. The diagnosis was also “de- rhagic cysts do not exhibit shading on T2-
finitive” when multiple hyperintense cysts were weighted images and will resolve with time (46).
seen on T1-weighted images regardless of their A follow-up examination (this can be done with
signal intensity on T2-weighted images. In their US) can confirm the diagnosis. Ovarian carci-
study, MR imaging yielded an overall sensitivity, noma can occasionally have internal hemorrhage.
specificity, and accuracy of 90%, 98%, and 96%, Visualization of solid components, septations, and
respectively. Because these cysts contain blood a size larger than expected for an endometrioma
products of different ages and concentrations, are features suggestive of malignancy.
cyst appearance can be variable. Those lesions Despite advances in technology, the diagnosis
that are not hyperintense on T1-weighted images of small endometriotic implants remains elusive.
can be difficult to distinguish from other adnexal Their signal intensity is quite variable. They may
masses (42,55). appear similar to normal endometrium (ie, low
Other lesions that appear with high signal in- signal intensity on T1-weighted images and high
tensity on T1-weighted images include dermoids, signal intensity on T2-weighted images), be hy-
mucinous cystic neoplasms, and hemorrhagic pointense with all pulse sequences, or be hyper-
masses. Dermoids can be recognized and differ- intense with all pulse sequences (Fig 17) (43,55,
entiated from endometriomas by the presence of 56). Implants can enhance with gadolinium; how-
chemical shift artifact and signal drop-out on the ever, this characteristic is neither sensitive nor
fat-suppression images. Mucinous lesions can specific (47).
have increased signal intensity on T1-weighted
Complications
Adhesions are an extremely common and impor-
tant complication of endometriosis, and an at-
RG ■ Volume 21 • Number 1 Woodward et al 207

a. b.
Figure 17. Endometriosis with an endometriotic cyst, implants, and adhesions. Axial T1-weighted (a) and
T2-weighted (b) MR images show the ovaries located more posteriorly than normally seen. The left ovary is
replaced by an endometrioma, which has low signal intensity on the T1-weighted image and which shows poste-
rior dependent shading on the T2-weighted image (solid curved arrow). There is a large endometriotic implant
on the surface of the right ovary, which has high signal intensity with both pulse sequences (open straight arrow).
Other implants were present at laparoscopy that were not seen on MR images. Note the adhesion extending
from the right ovary to the posterior pelvic wall (solid straight arrow in b), which is made conspicuous by fluid
on either side. Open curved arrow = uterus.

gentle external pressure to better examine the

pelvic organs and to detect if they are mobile or
fixed. Fixed pelvic organs (ie, a fixed retroverted
uterus) are suggestive of adhesions and should be
noted in the radiologic report. At MR imaging,
adhesions may sometimes be identified as spicu-
lated low-signal-intensity stranding that obscures
organ interfaces. Posterior displacement of the
uterus and ovaries, angulation of bowel loops, el-
evation of the posterior vaginal fornix, loculated
fluid collections, and a hydrosalpinx are also find-
ings that suggest the presence of adhesions (Figs
17, 18) (55). Unfortunately, the extent and se-
verity of adhesions can be difficult to determine
with imaging, and laparoscopy is required for de-
finitive diagnosis.
Figure 18. Adhesions from endometriosis. Sagittal Focal leaks with inflammation, fibrosis, and
T2-weighted MR image shows an elevated posterior adhesion formation are characteristics of endome-
vaginal fornix. Bowel loops are tethered to this same triosis, whereas acute cyst rupture is a relatively
area (arrow). These findings are subtle but suggestive uncommon complication. It has been reported in
of adhesions. Endometriotic implants (not seen on the
pregnancy and likely occurs because of softening
MR images) and adhesions were found at laparoscopy.
of the lesion from stromal decidualization com-
bined with pressure from the expanding uterus
tempt should be made to exclude them radiologi- (22). Patients with a ruptured cyst present with
cally. During a US examination, a modified symptoms of an acute abdomen.
“physical examination” can be performed. The
sonographer can use the transvaginal probe and
208 January-February 2001 RG ■ Volume 21 • Number 1

a. b.
Figure 20. Bilateral endometrioid carcinomas in a 30-year-old woman with pelvic pain and a palpable mass.
(a) Axial CT scan shows bilateral ovarian masses with large, enhancing solid components (arrows). (b) Pho-
tograph of the resected left ovary shows a large solid component, as well as blood within the cystic portion.
Endometriosis and endometrioid carcinoma were found at histologic analysis.

Malignant transformation is a well-described,

although rare (<1% of cases), complication of
endometriosis. Approximately 75% of these tu-
mors arise from endometriosis of the ovary (22).
Other less common sites include the rectovaginal
septum, rectum, and sigmoid colon (57). Unop-
posed estrogen therapy may play a role in the de-
velopment of such tumors (22,57). Endometrioid
carcinoma is the most common malignant neo-
plasm arising from endometriosis (Figs 19, 20),
followed by clear cell carcinoma (58,59). Even
when direct transition from endometriosis is not
visualized, there is a definite association of both
of these tumors with coexistent endometriosis
(22). Large lesions and those with solid compo-
nents suggest malignancy and must be removed
(Fig 21).

Atypical Sites of Implantation

Endometriosis can locally penetrate organs of Figure 19. Endometrioid carcinoma. Medium-
the gastrointestinal or urinary tracts or travel power photomicrograph (original magnification, ´32;
hematoxylin-eosin stain) shows endometriotic glands
outside the pelvis to distant sites. Patients with (open arrows) and well-differentiated endometrioid
atypical locations of disease present with unusual carcinoma (solid arrows).
symptoms, leading to a wide variety of radiologic
procedures being performed.
tients with endometriosis (22). It most com-
Gastrointestinal Tract monly affects those segments of bowel in the de-
Endometriotic implants of the gastrointestinal pendent portion of the pelvis and is rarely found
tract are estimated to occur in 12%–37% of pa- proximal to the terminal ileum (60). The most
commonly affected areas in decreasing order of
RG ■ Volume 21 • Number 1 Woodward et al 209

a. b.
Figure 21. Large atypical endometrioma in a 32-year-old woman with right-sided abdominal pain and infertility.
(a) CT image shows a complex right adnexal mass extending into the upper abdomen. Note the irregular nodular
enhancement within the wall of the mass (arrows). (b) Photograph of the gross specimen shows prominent soft-tissue
masses in the wall of the cyst. The findings are suggestive of malignancy, and the solid areas must carefully sampled.
Scale is in centimeters.

Figure 22. Endometriosis of the sigmoid colon in a 26-

year-old woman with abdominal pain and a palpable mass.
(a) Double-contrast barium enema image shows asym-
metric narrowing of the sigmoid colon with a crenulated
appearance of the affected wall (arrows). (b) Intraopera-
tive photograph shows endometriotic implants on the se-
rosal surface of the bowel.

frequency are the rectosigmoid colon, appendix,

cecum, and distal ileum (60,61). The implants
are usually serosal but can eventually erode
through the subserosal layers and cause marked
thickening and fibrosis of the muscularis propria.
An intact overlying mucosa is almost always
present, since the implanted tissue only rarely in-
vades through to the mucosa (60). Inflammatory
a. response to cyclic hemorrhage can lead to adhe-
sions, bowel stricture, and gastrointestinal ob-
struction.
The appearance of gastrointestinal implants
on double-contrast barium enema images is
variable, but the involvement is often asymmet-
ric, with puckering or a crenulated appearance of
the affected wall (Fig 22) (62). The differential
diagnosis includes metastatic disease, particu-
larly drop metastases from an upper abdominal

b.
210 January-February 2001 RG ■ Volume 21 • Number 1

b.
Figure 23. Endometriosis at the rectosigmoid junction
in a 28-year-old woman with menorrhagia and pelvic pain
who presented with a 6-week history of rectal bleeding.
(a) Double-contrast barium enema image shows circum-
ferential narrowing of the rectosigmoid colon (arrow).
(b) Photograph of the gross specimen shows marked
thickening of the bowel wall. In this case, the patient’s
clinical presentation, along with location and lack of mu-
cosal irregularity, were suggestive of endometriosis. Se-
vere endometriosis and dense adhesions were found at
surgery.
a.

malignancy. When endometriosis exhibits a

more circumferential, annular appearance, it may
be confused with a primary colon carcinoma (Fig
23). The CT and US appearances of endometri-
osis involving the bowel are nonspecific and usu-
ally do not help differentiate masses discovered at
barium enema imaging studies. MR imaging may
aid in the differentiation between an endometrio-
ma and tumor in selected cases (51,60).

Genitourinary Tract
Endometriotic implants may affect the urinary
tract in up to 20% of cases, but involvement is
usually asymptomatic except in conjunction with Figure 24. Endometriosis involving the bladder in a
severe pelvic disease (22,63). The bladder is the 42-year-old woman with hematuria and a history of
most frequently involved organ, followed by the pelvic endometriosis. Collimated view of the bladder
ureters. Only scattered cases of renal or urethral from an excretory urographic study shows an irregular
involvement have been reported (22). When the filling defect on the dome of the bladder (arrow). The
bladder is involved, endometriotic implants are appearance is nonspecific and requires biopsy to rule
often confined to the serosal surface but can infil- out malignancy.
trate the muscle and appear as mural masses pro-
jecting into the bladder lumen. These masses are
typically near the dome of the bladder and can be and cystoscopy with biopsy is required for a de-
seen during excretory urography or with US, CT, finitive diagnosis.
or MR imaging (Fig 24). This appearance is gen- The distal ureter is the most common ureteral
erally indistinguishable from that of a neoplasm, segment involved. Endometriotic foci may im-
plant on ureteral adventitia. Direct invasion of
the ureter can lead to hyperplasia and fibrosis of
RG ■ Volume 21 • Number 1 Woodward et al 211

Figure 25. Endometriosis of the distal right ureter in a 44-year-old woman with episodic painful
hematuria. (a) A 10-minute image from an excretory urographic study shows dilatation of the right
collecting system and proximal ureter (arrows). (b) Retrograde ureterogram shows a short, ta-
pered stricture in the distal right ureter (arrow). (c) Photograph of resected portions of the ureter
shows marked wall thickening and luminal narrowing.

a. b.

Chest
Well-documented endometriosis of the chest,
thoracic endometriosis syndrome (TES), is un-
common, and the diagnosis is usually established
on clinical grounds (64). The two theories enter-
tained for the development of TES are micro-
embolization and peritoneal-pleural migration. In
c. the microembolization theory, it is postulated that
endometrial tissue can be transported through the
lymphatic or vascular channels to the lung paren-
the muscularis and lamina propria, resulting in chyma. Alternatively, endometrial tissue may in-
luminal narrowing (22). Ureterography reveals a volve the pleura by migrating from the peritoneal
short or medium length ureteral stricture, usually cavity to the pleural cavity through diaphrag-
near the inferior aspect of the sacroiliac joint. matic defects. Pleural lesions are almost exclu-
The ureter may have a smooth stricture, abrupt sively right-sided, whereas lung lesions have no
tapering, and sharp medial angulation (Fig 25). such predilection (22). Regardless of pathophysi-
This narrowing can cause dilatation and even ology, TES is generally associated with coexistent
complete obstruction of the proximal ureter. pelvic endometriosis and usually occurs 5 years
These findings are nonspecific, and other causes after the diagnosis of pelvic endometriosis (64).
for ureteral stricture are in the differential diag-
nosis.
212 January-February 2001 RG ■ Volume 21 • Number 1

Figure 27. Parenchymal endometrioma in a 74-year-

old woman. The lesion was found on a routine preop-
erative chest radiograph obtained for cataract surgery.
She had been receiving estrogen replacement therapy
since undergoing hysterectomy but had no known his-
tory of endometriosis. Chest CT scan (lung windows)
Figure 26. Catamenial pneumothorax in a 42-year- shows a 2.5-cm solitary pulmonary nodule in the right
old woman who presented with three episodes of spon- lower lobe (arrow).
taneous pneumothorax, each associated with the onset
of menses. She had undergone a prior hysterectomy for
endometriosis and had a 2–3-year history of episodic
cough, hemoptysis, and pleuritic chest pain. Posteroan-
terior chest radiograph shows a right-sided pneumotho-
rax, as well as a nodular opacity in the right lung base
(arrow).

Notably, however, in some cases pulmonary le-

sions may actually represent embolic decidua or
trophoblastic tissue and are not from preexisting
endometriosis (22).
Radiographic findings include pneumothorax,
hemothorax, and lung nodules (Figs 26, 27). In a
recent series of 110 patients with TES, pneumo-
thorax was the presenting sign in 73%, hemotho-
rax in 14%, hemoptysis in 7%, and pulmonary
nodules in 6% (64). Treatment for recurrent
pneumothorax was more successful with surgical
pleurodesis than with medical management (64).

Cutaneous Tissues Figure 28. Medium-power photomicrograph (origi-

Endometriosis can occur within surgical scars, nal magnification, ´20; hematoxylin-eosin stain) shows
an endometriotic implant in the ectocervical stroma
generally from prior gynecologic operations. Un-
(curved arrow). At colposcopy, this lesion was thought
like the other atypical locations, endometriosis to represent a focus of high-grade squamous dysplasia.
within scars is accompanied by pelvic endometri- Straight arrows = extravasated blood, arrowheads =
osis in the minority of cases (22). Cervical disease normal squamous epithelium.
can occur in association with cervical trauma, typi-
cally cone biopsy or electrocautery. Lesions may
be friable and hemorrhagic and may simulate dominal wall endometriosis may occur after pel-
cervical carcinoma (Fig 28). Vulvar disease can vic surgery, whereas some lesions, such as those
be seen at the site of an episiotomy scar. Ab- of the umbilicus, are thought to occur spontane-
ously (22). Patients can present weeks to years
after surgery with a palpable mass or focal pain
associated with menses.
RG ■ Volume 21 • Number 1 Woodward et al 213

a. b.
Figure 29. Rectus muscle endometrioma in a 35-year-old woman with a history of prior abdominal hysterectomy
but not endometriosis. Transverse (a) and longitudinal (b) US scans of the abdominal wall show a hypoechoic mass
within the right rectus muscle (large arrows). The small arrow in a points to the midline. LL = left rectus muscle,
RR = right rectus muscle.

a. b.
Figure 30. Subcutaneous endometrioma in a 42-year-old woman with a 10-year history of a lump in her right
groin. (a) CT scan shows a soft-tissue-attenuation mass with surrounding inflammatory changes (arrow). (b) Low-
power photomicrograph (original magnification, ´8; hematoxylin-eosin stain) of the implant shows endometriotic
glands and stroma (arrows) scattered in a background of reactive fibrosis.

US features of abdominal wall endometriomas Treatment

are variable. Well-defined hypoechoic masses, Treatment for endometriosis can be expectant,
cystic masses, and complex cystic and solid masses medical, or surgical, depending on the severity of
have been described (Fig 29) (65–67). An inflam- symptoms and the patient’s desire to maintain or
matory reaction to the endometrial implant may restore fertility (7,13). Because no pharmacologic
be seen as a hyperechoic border at US or as tis- method has been proved to restore fertility, pa-
sue stranding at CT (Fig 30) (65). Differential tients with infertility secondary to endometriosis
diagnosis includes abscess, hematoma, hernia, se- are usually treated surgically or with advanced re-
baceous cyst, lipoma, hemangioma, and malig- productive techniques. Medical treatment is used
nant tumor (61). Imaging-guided fine needle as- for patients with pelvic pain or dyspareunia.
piration with cytologic analysis can help make the
diagnosis.
214 January-February 2001 RG ■ Volume 21 • Number 1

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