**11. Imaging and endometriosis**

Endometriomas are uncommon in the adolescent population, and information regarding the adnexa can be obtained noninvasively with a pelvic ultrasound. Ultrasound as the primary imaging investigation can aid in its diagnosis. Transvaginal ultrasound (TVUS) with color flow Doppler can detect endometriomas with a high degree of accuracy. Ultrasound is limited in its ability to detect small peritoneal implants and adhesions (74).

MRI is an excellent imaging modality for the evaluation of patients with deep pelvic endometriosis, showing high accuracy in the diagnosis and prediction of disease extent. The MRI diagnosis of deep pelvic endometriosis is based on the conjoint presence of signal intensity and morphologic abnormalities in the anterior and posterior compartments of the pelvis and the presence of surrounding fibrosis. The use of endovaginal and rectal contrast is useful to better delineate the anatomy and map out the extent of disease. Atypical locations of deep pelvic and extrapelvic endometriosis have been presented and grouped under the term anterior endometriosis. An accurate diagnosis therefore resides in clinical awareness and systematic review via MRI. A key finding of malignant transformation is the presence of enhancing nodules in the endometrial cyst on T1-weighted images (74, 75).
