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Pictorial Essay
Pelvic Endometriosis: Various Manifestations and MR
Imaging Findings
Christina A. Gougoutas 1, Evan S. Siegelman 1, Jennifer Hunt 2, Eric K. Outwater 3

E ndometriosis is defined as the

presence of endometrial glands in
locations outside the uterus. The
ectopic endometrium responds to hormonal
stimulation with various degrees of cyclic
hemorrhage that result in suggestive symp-
toms and appearances. Recent awareness of
the increasing incidence of endometriosis in
asymptomatic women has led to the hypothe-
sis that endometrial implants are in fact physi-
ologic and do not in themselves indicate a
disease process until recurrent bleeding occurs
in these implants, causing symptoms and pro-
gressive disease [1].
The three hallmarks of endometriosis are
peritoneal endometrial implants, endometriomas
(endometriotic cysts), and adhesions. The most
common peritoneal sites of involvement (in de-
creasing order of frequency) are the ovaries,
uterine ligaments, cul-de-sac, and pelvic perito-
neum reflected over the uterus, fallopian tubes,
rectosigmoid, and bladder. Rare extraperito-
neal sites include the lungs and the central
nervous system.
Because sonography is usually the first tech-
nique performed for evaluation of pelvic disease
during the reproductive years, it can aid diagno-
sis and treatment of endometriosis. Sonography
may not differentiate some endometriomas from
hemorrhagic cysts or other ovarian neoplasms
and is insensitive in the detection of peritoneal
implants. Because of these limitations, laparos-
copy has remained the standard of reference for
diagnosis and staging of pelvic endometriosis.
Laparoscopy does not visualize well “atypical”
nonpigmented extraperitoneal sites of involve-
ment and, particularly, regions obscured by pel-
vic adhesions. MR imaging may be an
alternative for evaluation of endometriosis be-
fore surgery. MR imaging has shown a sensitiv-
ity and specificity of greater than 90% in the
detection of endometriomas, with its main limi-
tation being the detection of small (<3 mm) peri-
toneal implants. The addition of fat-saturated
T1-weighted imaging has improved diagnostic
accuracy in the evaluation of both endometrio-
mas and peritoneal disease by narrowing the dy-
namic range, increasing lesion conspicuity [2],
and differentiating lipid-containing ovarian
masses from those containing blood [3] (Fig. 1).
This pictorial essay shows the imaging spectrum
of endometriosis with emphasis on unusual pel-
vic manifestations.
Endometrial Implants
The peritoneal implant represents the
presence of endometrial surface epithelium
and stroma embedded in serosal tissues in
the peritoneal cavity. The ectopic location of
endometrium in the peritoneal cavity causes
reactive proliferation of the stromal vessels
that leads to recurrent hemorrhage. The im-
plant has a varied appearance depending on
the age of associated blood products. Patho-
logically, the implants begin as red highly
vascular lesions, typically 2–3 mm. Recur-
rent bleeding and inflammation cause fibro-
sis and hemosiderin deposition, leading to a
raised nodular “powder burn” lesion. Lack of
detection of these small foci of peritoneal in-
volvement has been a major limiting factor
in the acceptance of MR imaging as a stag-
ing tool for pelvic endometriosis.
Endometriomas
Endometriomas (“chocolate cysts”) of the
ovary contain dark gelatinous material sur-
rounded by a fibrous wall of variable thick-
ness. Endometriomas are usually multiple
and bilateral. They are characteristically ho-
mogeneously hyperintense on T1-weighted
sequences with relatively low signal intensity
on T2-weighted sequences (Fig. 2). This loss
of signal intensity on the T2-weighted se-
quences is caused by high concentrations of

Received November 15,1999; accepted after revision January 24, 2000.

1
Department of Radiology, University of Pennsylvania Medical Center, 3400 Spruce St.,1st Floor Silverstein, Philadelphia, PA 19104-4283. Address correspondence to E. S. Siegelman.
2
Department of Pathology, University of Pennsylvania Medical Center, 6th Floor Founders, Philadelphia, PA 19104-4283.
3
Department of Radiology, University of Arizona Medical Center, 1501 N. Campbell Ave., Rm. 1361, Tucson, AZ 85724-5067.

AJR 2000;175:353–358 0361–803X/00/1752–353 © American Roentgen Ray Society

AJR:175, August 2000 353

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A B C

Fig. 1.—38-year-old woman with left-sided ovarian dermoid cyst, endometrioma, and right-sided ovarian corpus luteum.
A, Axial T1-weighted MR image (TR/TE, 550/14) shows two high-signal-intensity masses (arrows) in left ovary.
B, Axial T2-weighted fast spin-echo MR image (4000/120) shows left-sided masses (arrows) to be heterogeneous in signal intensity. Note involuting corpus luteum
(arrowhead) in right ovary.
C, T1-weighted fat-saturated MR image (270/1.8) shows anterior mass (open arrow) to be predominantly fatty and posterior mass to be hemorrhagic (solid arrow). Left-
sided ovarian dermoid cyst and endometrioma were proven at surgery.

A B C

Fig. 2.—42-year-old woman with right-sided endometrioma and cul-de-sac endometrial implants.
A, T1-weighted spin-echo MR image (TR/TE, 450/16) shows high-signal-intensity mass (E) representing en-
dometrioma. Anterior rectal wall thickening is present (arrow).
B, T2-weighted fast spin-echo MR sequence (4650/126) shows endometrioma (solid arrow) with low signal inten-
sity. Fibrotic cul-de-sac implant (open arrow) infiltrates perirectal fat. A = adenomyosis.
C, T1-weighted fat-saturated gradient-echo MR image (250/2.9) after administration of IV gadopentetate dimeglumine
shows layered appearance of endometrial wall (solid arrow) with low-signal-intensity layer. Fibrotic cul-de-sac im-
plant shows enhancement (open arrow).
D, Photomicrograph of histopathologic specimen shows endometrial wall with fibrosis (F) and hemosiderin deposition
(large arrows). Inset shows endometrial glands (small arrows) along another part of cyst wall. (H and E, ×40)
D

intracystic methemoglobin and other protein products are in various stages of degradation tion of iron increases along with the viscosity
or iron products [4]. Some lesions are hetero- from multiple episodes of bleeding. As free of the cyst contents. Takahashi et al. [5] have
geneous in signal intensity because the blood water in the cyst is resorbed, the concentra- shown the density (chronicity) of cyst con-

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A B C
Fig. 3.—33-year-old woman with endometrioma of left ovary and ovarian torsion.
A, T1-weighted spin-echo MR image (TR/TE, 450/8) shows high-signal-intensity cystic structures (arrows) surrounded by intermediate-signal-intensity tissue.
B, T1-weighted fat-saturated gradient-echo MR image after administration of IV gadopentetate dimeglumine shows low-signal-intensity poorly enhancing ovarian stroma
(arrows) around endometriomas (B). Soft tissue around central endometrioma shows high-signal-intensity ovarian stroma with cortex displaced peripherally.
C, Sagittal T2-weighted fast spin-echo MR image (6000/140) shows displaced follicles (arrowheads) at periphery of markedly enlarged torsed ovary (arrows).

A B C
Fig. 4.—42-year-old woman with endometriomas, hematosalpinx, and corpus luteum.
A and B, Axial T1-weighted MR image (A) (TR/TE, 500/8) reveals two high-signal-intensity foci in left ovary that lose signal intensity on T2-weighted MR image (B) (5800/
100), representing endometriomas (open arrow). Adjacent corpus luteum (arrowhead) shows heterogeneous signal intensity and higher signal intensity on T2-weighted
image than endometriomas showed. Note presence of simple ovarian cyst (asterisk). Solid arrow indicates hematosalpinx.
C, Sagittal T2-weighted MR image (3550/140) shows oval structure adjacent to cul-de-sac to represent hematosalpinx (solid arrow). Open arrow indicates endometriomas.
Asterisk indicates ovarian cyst.

tents to be directly proportional to the iron
concentration, with a corresponding decrease
in the T2 relaxation time as the concentration
of iron and the viscosity of cyst fluid in-
crease. Iizuka et al. [6] have also shown that
the concentration of iron in an ovarian cyst
helps in differentiating endometriomas from
serous cystadenocarcinomas, which do not
contain a high concentration of iron.
Endometriotic cysts may contain a periph-
eral rim of low signal intensity representing
hemosiderin or fibrous capsule (Fig. 2). En-
hancement of the periovarian peritoneal sur-
faces after contrast material administration
may occur [7] (Fig. 2). Large endometriomas
may contain multiple thin septations and fre-
quently show hematocrit levels.
Endometriomas may predispose the ovary to
twist less often than other ovarian masses, pos-
sibly because of surrounding adhesions. The di-
agnosis of ovarian torsion may be established
with MR imaging by showing an endometri-
oma in an enlarged poorly enhancing ovary
with peripherally located follicles (Fig. 3).
Hydrosalpinx
Approximately 30% of women with en-
dometriosis have associated tubal abnormalities
present at laparoscopy [8]. Hydrosalpinges have
a tubular, often folded, configuration and can be
differentiated from other adnexal masses on
MR imaging by the use of multiple imaging
planes. Dilated fallopian tubes with high signal
intensity on T1-weighted sequences are associ-
ated with endometriosis. These fallopian tubes
do not always show T2 shortening typical of en-
dometrial cysts. In addition, debris can be
present within the dependent portions of the
tube (Fig. 4). A complicated hydrosalpinx may
be the only imaging finding indicating en-
dometriosis (Fig. 5). Although the presence of
complicated hydrosalpinges may not influence
patient treatment, it does increase the specificity
for pelvic endometriosis.

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A B
Fig. 6.—26-year-old woman with ovarian and rectal en-
Fig. 5.—43-year-old woman with endometriosis of left fallopian tube. dometriosis. T1-weighted spin-echo image (TR/TE, 700/
A, T1-weighted spin-echo MR image (TR/TE, 500/8) shows dilated left fallopian tube with high signal intensity 16) shows single right-sided ovarian endometrioma (open
(arrow), consistent with hematosalpinx. arrow) and spiculated fibrotic mass of endometriosis with
B, Photomicrograph of histopathologic specimen of tubal wall shows abundant interstitial hemorrhage (H) punctate high-signal-intensity foci (solid arrow). T2-
and endometrial glands (arrowhead). L= tubal lumen. (H and E, ×100) weighted MR images showed mass to be low signal inten-
sity (not shown), reflecting fibrous content.

Fig. 7.—26-year-old woman with solid endometriosis

in cesarean section scar.
A, Sagittal T2-weighted MR image (TR/TE, 4816/135)
shows low-signal-intensity spiculated mass (arrow) in
surgical incision extending to and contiguous with
uterus. This mass showed high signal intensity on T1-
weighted sequences and avid enhancement after gado-
pentetate dimeglumine administration (not shown).
B, Photomicrograph of histopathologic specimen
shows abundant fibrous tissue (F) surrounding scat-
tered endometrial glands (G). Scar endometriosis is
likely caused by direct implantation of endometrial
glands as opposed to more common cause of retro-
grade menstruation. (H and E, ×100)
A B

Solid Endometriosis
Deep nodular (solid) endometriosis is typi-
cally found in the rectovaginal septum and in
other fibromuscular pelvic structures such as the
uterine ligaments and the muscular wall of pel-
vic organs. The endometrial glands and stroma
infiltrate the adjacent fibromuscular tissue and
elicit smooth muscle proliferation and fibrous
reaction, resulting in solid nodule formation.
MR imaging characteristics of these solid
masses have been described as low to intermedi-
ate in signal intensity with punctate regions of
high signal intensity on T1-weighted images,
uniform low signal intensity on T2-weighted im-
ages, and enhancement corresponding to the
abundant fibrous tissue seen in these lesions at
histologic examination (Fig. 6). The punctate
foci of high signal intensity represent regions of
hemorrhage surrounded by solid fibrotic tissue.
These solid masses of endometriosis may
simulate metastatic peritoneal implants from
intraperitoneal malignancies such as ovarian
carcinoma. These disease processes can be
differentiated by the low signal intensity on
T2-weighted sequences of solid endometrio-
sis, often in combination with the presence of
endometrial cysts. Solid endometriosis can
also develop in cesarian section scars involv-
ing Pfannenstiel’s incision after cesarian sec-
tion (Fig. 7).
Some masses of endometriosis are com-
posed of a large proportion of glandular mate-
rial with little fibrotic reaction that results in
high signal intensity on T2-weighted images.
This solid glandular material will enhance
with contrast material administration, thus dis-
tinguishing it from necrosis or intratumoral
hemorrhage (Fig. 8).
Visceral Endometriosis
Solid endometriosis can involve the ali-
mentary and urinary tracts. Bladder involve-
ment has been described, and similarly the
ureter may be involved. Urinary tract disease
may present as hydronephrosis caused by
ureteral obstruction (Fig. 9) or as a submu-
cosal lesion within the bladder or ureter (Fig.
10). The rectosigmoid is the most common
segment of bowel involved. The implants ad-
here to the serosal surface of the bowel and
may invade the muscle layers, eliciting
marked smooth muscle proliferation. Stric-
ture formation and obstruction may result.
Malignant Transformation of
Endometriosis
Malignant transformation is a rare complica-
tion of endometriosis, the exact incidence and
prevalence of which is unknown. Criteria for di-
agnosis include adjacent benign and malignant
endometrial tissues without findings to suggest
metastatic disease from another primary site.

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A B C
Fig. 8.—Solid glandular endometriosis in 37-year-old woman.
A, Axial T2-weighted MR image (TR/TE, 4700/105) shows mass in cul-de-sac (arrow) to be high signal intensity, atypical
for solid endometriosis.
B, T1-weighted fat-saturated MR image (350/1.8; flip angle, 90°) shows mass (arrow) to contain high-signal-in-
tensity hemorrhage.
C, T1-weighted fat-saturated gadolinium-enhanced MR image (350/1.8) shows mass (arrow) to enhance, show-
ing it is not primarily fluid.
D, Photomicrograph of resected tissue shows extensive glands (arrowheads). S = endometrial stroma. (H and E, ×40)

A B C
Fig. 9.—Ureteral endometriosis in 68-year-old woman.
A, Coronal T2-weighted single-shot fast spin-echo MR image (TR/TE, infinite/99) shows left ureteral obstruction (arrow) causing hydronephrosis.
B, Sagittal T2-weighted fast spin-echo MR image (4000/140) shows solid low-signal-intensity endometriosis (arrow) obstructing left ureter (arrowheads) at pelvic inlet.
C, T1-weighted MR image (483/8) shows high-signal-intensity foci in mass (arrow). Endometriosis causing obstruction was proven at surgery.

The histologic patterns reflect an endometrial from stromal tissues (Fig. 11). Endometriomas Summary
origin and include endometrioid adenocarci- with solid components and intermediate or high MR imaging has become an increasingly ac-
noma and clear cell carcinoma from glandular signal intensity on T2-weighted images or pap- cepted technique in the diagnosis and character-
elements and endometrial stromal sarcoma illary projections are suggestive of malignancy. ization of endometriosis. Limitations remain

AJR:175, August 2000 357

 Gougoutas et al.
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A B C
Fig. 10.—42-year-old woman with right-sided ureteral endometriosis causing obstruction.
A, Coronal T2-weighted fast spin-echo MR image (TR/TE, 6000/119) shows dilated right ureter (arrow).
B and C, T1-weighted gradient-echo MR images (350/2.9) before (B) and after (C) administration of IV gadopentetate dimeglumine show enhancement of polypoid structure
in right ureter (white arrow). Right ureteroscopy and biopsy showed endometrial glands and stroma. Right ovarian endometrioma is present (black arrow, B).

Fig. 11.—50-year-old woman with endometrial stro-

mal sarcoma arising in endometriosis.
A, T1-weighted spin-echo MR image (TR/TE, 500/16)
shows mass (solid arrow) adjacent to hemorrhagic
fluid collection (open arrow).
B, T2-weighted fast spin-echo MR image (4000/126)
shows solid mass (solid arrow) behind hemorrhagic
collection (open arrow). Mass was excised and
shown to be low-grade endometrial stromal sarcoma
arising in endometriosis.
A B

regarding detection of small peritoneal implants
and atypical implants, identifying adhesions, and
accurate staging of the disease. However, as il-
lustrated in this pictorial essay, the common and
less typical manifestations of endometriosis have
suggestive findings on MR imaging because of
the underlying proteinaceous, hemorrhagic, or
fibrous content of these lesions.
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