Navigating complexity: review and updates of endometriosis and adenomyosis imaging

Endometriosis and adenomyosis are prevalent chronic inflammatory conditions that significantly impact reproductive-age women, leading to debilitating symptoms such as pelvic pain, dysmenorrhea and infertility. Endometriosis is characterized by ectopic endometrial tissue outside the uterus, while adenomyosis involves endometrial deposits within the myometrium, often causing overlapping symptoms. Accurate diagnosis is essential for effective management, yet challenges persist due to variability in lesion location and presentation. Imaging plays a crucial role in the diagnosis, staging, and management of these conditions. While transvaginal ultrasound (TVUS) remains a reliable first-line tool with high specificity, magnetic resonance imaging (MRI) offers superior sensitivity, particularly for endometriomas and deep endometriosis. Both modalities have their limitations but are complementary in preoperative assessment and treatment planning. Emerging imaging protocols, classification systems, and advancements such as dynamic TVUS and improved MRI techniques are discussed. Despite significant progress, the lack of a universally accepted classification system and standardized imaging protocols highlights the need for further research. Advancing diagnostic accuracy and treatment strategies through imaging holds promise for improving patient outcomes. This article reviews the pathophysiology, staging and subtypes of endometriosis and adenomyosis. Recent society guidelines are addressed and readers are provided with updates on imaging technologies with insights into future directions.