New ACOG Guidelines Change How Endometriosis Is Diagnosed

Endometriosis affects an estimated 1 in 10 women of reproductive age, yet it often takes years to diagnose. New diagnostic recommendations from the American College of Obstetricians and Gynecologists (ACOG) aim to change that by helping clinicians identify and treat the condition earlier and more efficiently.

At Fertility Centers of New England, our reproductive endocrinologists closely follow emerging clinical guidance to ensure patients receive evidence-based, compassionate fertility care. The updated ACOG recommendations emphasize earlier clinical diagnosis, targeted imaging, and symptom-based evaluation, which may help shorten the long diagnostic journey many patients experience.

Below, we break down what the new guidance means for patients experiencing symptoms of endometriosis or struggling with infertility.

What Is Endometriosis?

Endometriosis occurs when tissue similar to the lining of the uterus grows outside the uterus, often affecting the ovaries, fallopian tubes, pelvic lining, and surrounding organs. These growths can cause inflammation, scarring, and pain, and may interfere with fertility.

Common symptoms include:

• Chronic pelvic pain
• Painful periods (dysmenorrhea)
• Pain during intercourse (dyspareunia)
• Painful urination or bowel movements
• Gastrointestinal symptoms such as bloating or constipation
• Fatigue
• Difficulty getting pregnant

Because symptoms can vary widely and sometimes overlap with other conditions, diagnosis has historically been challenging.

ACOG’s New Approach: Clinical Diagnosis First

One of the most significant updates from ACOG is that a clinical diagnosis may be sufficient to begin treatment.

This means doctors can diagnose suspected endometriosis based on:

• Patient symptoms
• Medical history
• Physical examination

Previously, many patients were told that laparoscopic surgery was required to confirm the condition. While surgery remains an option in some cases, the new guidance encourages clinicians to begin empiric treatment earlier, potentially helping patients get relief sooner.

This change may reduce the years-long delay many patients face before receiving treatment.

Symptoms That May Suggest Endometriosis

ACOG recommends that clinicians consider endometriosis in patients who experience one or more of the following:

Pelvic Symptoms

• Chronic pelvic pain lasting 6 months or longer
• Severe menstrual cramps
• Pain with intercourse
• Painful urination
• Painful bowel movements

Fertility Concerns

• Difficulty conceiving or unexplained infertility

Gastrointestinal or Other Symptoms

• Bloating, constipation, or diarrhea linked to menstrual cycles
• Rectal bleeding during menstruation
• Shoulder or chest pain in rare thoracic cases
• Sciatic nerve pain
• Fatigue or malaise

Patients with a family history of endometriosis may also have an increased risk.

Imaging Recommendations: Ultrasound First

Another key recommendation from ACOG is the use of transvaginal ultrasound as the first imaging test when endometriosis is suspected.

Ultrasound can help identify:

• Ovarian endometriomas (“chocolate cysts”)
• Pelvic masses
• Structural abnormalities

If a transvaginal ultrasound is not appropriate, transabdominal ultrasound may be used as an alternative.

For more complex or deep forms of the disease, clinicians may recommend pelvic MRI to better map the extent of endometriosis before treatment planning.

Biomarkers Are Not Recommended for Diagnosis

Despite ongoing research, ACOG does not recommend using blood tests, urine tests, or endometrial biomarkers to diagnose endometriosis.

Currently, these tests lack sufficient accuracy and reliability for routine clinical diagnosis.

Instead, clinicians should rely on:

• Symptom evaluation
• Physical examination
• Imaging when appropriate

Endometriosis and Infertility

Endometriosis is one of the leading causes of infertility, affecting up to 30–50% of individuals with the condition.

The disease may impact fertility by:

• Causing inflammation that affects egg quality
• Distorting pelvic anatomy
• Blocking fallopian tubes
• Interfering with implantation

At Fertility Centers of New England, fertility specialists evaluate how endometriosis may affect each patient’s ability to conceive and develop personalized treatment strategies, which may include:

• Fertility medications
• Intrauterine insemination (IUI)
• In vitro fertilization (IVF)
• Surgical management when appropriate

Early evaluation can help improve reproductive outcomes.

Why Earlier Diagnosis Matters

For many patients, endometriosis symptoms are dismissed or misunderstood for years. The updated guidance from ACOG emphasizes that patient-reported symptoms are clinically meaningful and should be taken seriously.

Earlier recognition may lead to:

• Faster symptom relief
• Reduced disease progression
• Improved fertility outcomes
• Better quality of life

When to See a Fertility Specialist

You may benefit from evaluation by a fertility specialist if you experience:

• Pelvic pain affecting daily life
• Severe menstrual pain that disrupts work or school
• Difficulty conceiving after 6–12 months of trying
• A known history of endometriosis

The reproductive endocrinology team at Fertility Centers of New England provides comprehensive evaluation and treatment for patients experiencing endometriosis-related infertility.

Frequently Asked Questions About the New Endometriosis Diagnosis Guidelines

What are the new ACOG recommendations for diagnosing endometriosis?

The American College of Obstetricians and Gynecologists now recommends that clinicians can make a clinical diagnosis of endometriosis based on symptoms, patient history, and physical examination. This allows treatment to begin earlier without requiring surgical confirmation in many cases.

Does endometriosis still require surgery to diagnose?

Not always. In the past, laparoscopic surgery was commonly used to confirm endometriosis. The updated recommendations allow clinicians to begin treatment based on symptoms and clinical evaluation, which may reduce delays in care.

What imaging tests are recommended for endometriosis?

ACOG recommends transvaginal ultrasound as the first imaging test for suspected endometriosis. If further evaluation is needed, a pelvic MRI may be used to assess deeper disease.

What symptoms may suggest endometriosis?

Symptoms may include chronic pelvic pain, severe menstrual cramps, pain during intercourse, painful bowel movements or urination, gastrointestinal symptoms such as bloating or constipation, and infertility.

Can blood tests diagnose endometriosis?

No. ACOG advises against using blood, urine, or other biomarkers to diagnose endometriosis because they are not accurate enough for clinical use.

How does endometriosis affect fertility?

Endometriosis can affect fertility by causing inflammation, scarring, and changes to pelvic anatomy. These changes may interfere with egg quality, fertilization, or embryo implantation.

When should I see a fertility specialist for endometriosis?

You should consider seeing a fertility specialist if you have persistent pelvic pain, severe menstrual symptoms, a known diagnosis of endometriosis, or difficulty conceiving after 6–12 months of trying.