The diagnosis and treatment of endometriosis depends very much on whether or not you are trying to conceive as well. Some women with early-stage endometriosis have little or zero pelvic pain or fertility issues. We used to diagnose these women when they had a laparoscopy to tie their tubes (there are now less invasive ways to block the tubes in women who are done with childbearing).
The ‘gold standard’ for diagnosis is still to perform a diagnostic/operative laparoscopy, an outpatient surgery performed under anesthesia where a small incision below your belly button allows us to pass a surgical telescope into your abdomen and pelvis and look for endometriosis and often destroy or cut out endometriosis if we find it. More advanced endometriosis may show up on pelvic ultrasound (a sonogram which is best perfomed with a transvaginal probe), bur early-stage endometriosis will not show up on ultrasound. If you are trying to conceive, a hysterosalpingogram (HSG) does not ‘see’ endometriosis but looks for blocked tubes or scar tissue around the tubes, which can occur in women who have endometriosis, as well as for other reasons like past infections.
If you’re not trying to conceive and your main problem is pelvic pain, while it’s more satisfying to have a ‘proven’ diagnosis, it is acceptable to treat the pain with medications (Depo-Lupron shots) without performing a laparoscopy first.
If you are trying to conceive, having endometriosis may change the course of your treatment in subtle or obvious ways. Having endometriosis (and surgical endometriosis treatment) may cause diminished ovarian reserve (low egg supply), scarring around the tubes or pelvic adhesions (scar tissue), or both. Some women with endometriosis need in vitro fertilization (IVF) to deal with these issues, and Depo-Lupron shots before IVF may improve success rates.