Imaging for Endometriosis in Adolescents

Imaging modalities should investigate in the adolescent and young women evidence for an endometrioma, the association with pouch of Douglas (POD) occlusion, and the rare but possible presence of deep infiltrating endometriosis (DIE), and finally, the presence of adenomyosis is of particular importance. The systematic approach proposed by International Deep Endometriosis Analysis (IDEA) group includes four basic steps. The first step, a routine evaluation of uterus and adnexa aimed to identify the sonographic signs of adenomyosis and/or presence or absence of endometrioma. The typical ultrasonographic appearance of endometrioma is a cystic lesion with “ground glass” echogenicity, well defined from the surrounding ovarian parenchyma, with no papillary projections or vascularized solid areas. The accuracy of ultrasound is significant in young patients with a sensitivity of 90% and a specificity of 97%. The second step includes evaluation of transvaginal sonographic “soft markers” (i.e., site-specific tenderness and ovarian mobility). The third step is an assessment of the status of pouch of Douglas using real-time ultrasound-based “sliding sign.” This sign is an easy method to assess pelvic adhesions and/or the presence of endometriosis in the posterior compartment and to assess the obliteration of POD. Finally, the fourth step is an assessment for deep infiltrating endometriosis nodules in anterior and posterior compartments. Based on a recent meta-analysis, the diagnostic performance of TVS and MRI to assess DIE lesions in rectosigmoid, uterosacral ligaments, and rectovaginal septum seems to be similar.