ESUR Experts Redefine MRI Standards in Endometriosis

MRI becomes the key imaging tool for suspected endometriosis under new ESUR recommendations.

Key Points

Highlights:

• The European Society of Urogenital Radiology (ESUR) published its 2025 updated consensus on MRI for diagnosing and mapping endometriosis:
• The update emphasizes MRI as the next-line imaging modality after inconclusive ultrasound results.
• The consensus introduces the deep pelvic endometriosis index (dPEI) and promotes structured reporting for better communication between radiologists and surgeons.

Importance:

• Endometriosis is complex, heterogeneous and requires precise preoperative mapping for optimal management.
• The new ESUR recommendations provide a standardized MRI protocol, terminology, and classification system, ensuring consistency across institutions and improving multidisciplinary communication.

What's Done Here?

• A panel of 21 ESUR experts from 10 countries reviewed current evidence and clinical experience to develop updated consensus guidelines for MRI evaluation of endometriosis.
• The recommendations address patient preparation, MRI sequences, structured reporting templates, and lesion localization according to standardized anatomical compartments.

Key Results:

• MRI should be performed after inconclusive ultrasound in suspected endometriosis cases.
• Standard MRI protocols should include T2-weighted sequences in multiple planes, with T1-weighted fat-saturated images to identify hemorrhagic foci.
• Use of structured reports and the dPEI scoring system is strongly encouraged to describe disease extent and predict surgical complexity.
• The consensus highlights radiologist–clinician collaboration as essential for improving diagnosis and treatment planning.

Strengths and Limitations:

• Strengths are that this consensus provides a comprehensive and standardized framework for MRI evaluation of endometriosis, improving communication, reproducibility, and surgical planning.
• Limitation: Study reflects expert opinion rather than prospective validation, requiring further studies to assess real-world impact on outcomes.

From the Editor-in-Chief – EndoNews

"This landmark ESUR consensus is more than a technical update—it is a roadmap toward global consistency in imaging women with endometriosis. For years, diagnostic variability and fragmented communication between radiologists and surgeons have limited the value of preoperative imaging. By establishing standardized MRI protocols and structured reporting, the ESUR provides a common language that connects radiologic findings with surgical planning and patient counseling.

The introduction of the deep pelvic endometriosis index (dPEI) represents a major step forward in quantifying disease complexity and improving the comparability of reports across centers. Equally important is the recognition that MRI complements, rather than replaces, high-quality ultrasound—each playing a pivotal role in accurate lesion mapping.

This consensus reminds us that imaging is not an isolated act of diagnosis but an integral part of multidisciplinary decision-making. When used systematically, MRI can transform the preoperative landscape of endometriosis—from descriptive imaging to predictive, communication-driven care."

Lay Summary

Magnetic resonance imaging (MRI) has become a cornerstone in diagnosing and mapping endometriosis, especially when ultrasound results are inconclusive.

The European Society of Urogenital Radiology (ESUR) has now published an updated 2025 consensus that redefines how MRI should be performed, interpreted, and reported in women with suspected or confirmed endometriosis.

This multidisciplinary document, developed by 21 experts from 10 countries, chaired by Dr.Thomassin-Naggara and Dr.Lucia Manganaro, provides detailed recommendations on patient preparation, MRI protocols, and structured reporting templates.

It highlights the need for standardization across imaging centers to ensure consistent diagnosis, reproducibility, and better communication among radiologists, gynecologists, and surgeons.

One of the key innovations is the introduction of the deep pelvic endometriosis index (dPEI), a new scoring system designed to describe disease extension and predict surgical complexity.

The consensus also emphasizes MRI’s complementary role to ultrasound, particularly in detecting deep infiltrating endometriosis and evaluating the rectovaginal septum, uterosacral ligaments, and bladder or bowel involvement.

By promoting a unified MRI terminology and structured reporting, the ESUR aims to reduce variability in interpretation and enhance preoperative planning and patient counseling.

These updated guidelines represent a major step toward global harmonization of imaging standards, improving both diagnostic accuracy and multidisciplinary collaboration in endometriosis care.

Research Source: https://pubmed.ncbi.nlm.nih.gov/40425757/