The Many Appearances of Endo

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Endometriosis has been described as appearing in many different colors: clear, white, red, yellow, brown, and black (Yeung, Sinervo, Winer, & Albee, 2011). Lesions have also been described as “petechial, vesicular, polypoid, hemorrhagic, red flame-like” (Agarwal & Subramanian, 2010). The appearance of endometriosis is important when surgery is performed to diagnose and treat endometriosis- otherwise it might be missed.



“Endometriosis has many different appearances that can make the diagnosis challenging and may necessitate histologic confirmation. “Subtle” or “atypical” appearance has been described as “red” or “white” lesions, or “clear” vesicles. Endometriosis in teenagers has been found to be more atypical in appearance. Some believe that with enhanced magnification available with modern-day laparoscopy, virtually all endometriosis can be identified.”

“…black, dark-brown, or bluish puckered lesions, nodules or small cysts containing old hemorrhage surrounded by a variable extent of fibrosis. Atypical or ‘subtle’ lesions are also common, including red implants (petechial, vesicular, polypoid, hemorrhagic, red flame-like) and serous or clear vesicles. Other appearances include white plaques or scarring and yellowish brown peritoneal discoloration of the peritoneum. Endometriomas usually contain thick fluid like tar; such cysts are often densely adherent to the peritoneum of the ovarian fossa and the surrounding fibrosis may involve the tubes and bowel. Deeply infiltrating endometriotic nodules extend >5 mm beneath the peritoneum and may involve the uterosacral ligaments, vagina, bowel, bladder, or ureters. The depth of infiltration is related to the type and severity of symptoms.”

“The classic black lesions were found to be painful in only 11% of patients when the lesion was touched. Similarly, white lesions were painful in 20% of patients with red lesions at 37%, and clear lesions at 32% were the most painful. These results added further reason as to why initial therapy had such poor results. Surgeons would only “see” the black lesions and removed them, but these were the least painful lesions. The most painful clear lesions were not “seen” at laparotomy and therefore remained, as did the pain.”

  • Donnez, J., Squifflet, J., Casanas-Roux, F., Pirard, C., Jadoul, P., & Van, A. L. (2003). Typical and subtle atypical presentations of endometriosis. Obstetrics and gynecology clinics of North America30(1), 83-93. Retrieved from

“The diagnosis of peritoneal endometriosis at the time of laparoscopy is often made by the observation of typically puckered black or bluish lesions. There are also numerous subtle appearances of peritoneal endometriosis. The lesions are frequently non-pigmented. Red flame-like lesions, glandular excrescences, and subovarian adhesions must be considered as the most active lesions. Sometimes, however, subtle endometriotic lesions can be the only lesions seen at laparoscopy.”

“Endometriosis is a disease of protean appearances and, when present on the superficial peritoneum, may assume a range of coloration, from the obvious to the very subtle. The exact extent of a lesion may be difficult to judge because subtle lesions merge with normal peritoneum. An inflammatory reaction occurs in most, but not all superficial lesions. Endometriotic lesions are angiogenic and create an altered microvascular pattern on the peritoneal lining.”

  • Albee Jr, R. B., Sinervo, K., & Fisher, D. T. (2008). Laparoscopic excision of lesions suggestive of endometriosis or otherwise atypical in appearance: relationship between visual findings and final histologic diagnosis. Journal of Minimally Invasive Gynecology15(1), 32-37. Retrieved from

“The greatest number of patient lesions were excised from cul-de-sac (n = 309). For this site, using visual criteria for diagnosis of endometriosis, positive predictive value was 93.9%, sensitivity was 69.3%, negative predictive value was 41.9%, and specificity was 83.1%. Prevalence was noted to be 79.0% and accuracy was 72.2%. In addition, atypical-appearing tissue not presumed to be endometriosis was confirmed to be endometriosis histologically in 24.3%. In examining tissue specimens from multiple anatomic sites, laparoscopic visual diagnosis of typical endometriosis generally had high positive predictive value. However, both sensitivity and negative predictive value were lower than expected because of atypical lesions subsequently diagnosed as endometriosis. Conclusions: These data suggest that when the surgical objective is complete eradication of endometriosis, the surgeon must be prepared to excise all lesions suggestive of endometriosis and tissue atypical in appearance as in most anatomic sites approximately 25% of atypical specimens proved to be endometriosis.”