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Dan C. Martin, MD
UT Medical Group, Inc.

University of Tennessee Health Science Center (UTHSC)

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Daniel Clyde Martin, M.D.
UT Medical Group, Inc.
Infertility and Gynecology
Reproductive Surgery
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Germantown, Tennessee
TN 38138-1733

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Glenn Ann Martin, Ph.D.
Clinical Psychologist

Protean Appearance of Endometriosis

Adapted from "Recognition of Endometriosis" in
Laparoscopic Appearance of Endometriosis, Lecture Supplement
Martin DC (ed), Resurge Press, Memphis, (c)1991

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Color Atlas

The diagnosis of endometriosis has often been made by observation of puckered black or bluish "typical" lesions. (Buttram & Reiter, 1985; Dmowski, 1984; Haney, 1987; Hulka, 1985; Kirshon, Poindexter, & Fast, 1989) These type lesions are common in the patient groups studied. Williams documented a 50% incidence in 968 patients who had an average age of 30. Publication have generally had average ages of 28 to 32. However, Williams' article excluded patients under 15 and those past the age of menopause. (Williams & Pratt, 1977) Patients with pain do not have laparoscopy as early as women with infertility. (Dmowski, Lesniewicz, Rana, Pepping, & Noursalehi, 1997) This results in biased data.


Dark lesions are the easiest to see and document. (Jansen & Russell, 1986; Martin, Hubert, Vander Zwaag, & El-Zeky, 1989; Moen & Halvorsen, 1992; Stripling, Martin, Chatman, Vander Zwaag, & Poston, 1988a; Stripling, Martin, & Poston, 1988b)


Subtle forms are more common. (Davis & Brooks, 1988; Martin, et al., 1989; Redwine, 1987a)


Subtle forms may be more active than dark lesions. (Vernon, Beard, Graves, & Wilson, 1986; Wild & Wilson, 1987)


Hidden retroperitoneal disease is active. (Koninckx, Ruttinen, Seppala, & Cornillie, 1992)

The subtle hue and color changes make diagnosis by direct visualization difficult (Dmowski, 1984) and endometriosis has been diagnosed by taking biopsies of areas of normal peritoneum. (Murphy, Green, Bobbie, Dela Cruz, & Rock, 1986; Steingold, Cedars, Lu, Randle, Judd, & Meldrum, 1987) Lesions can hide in or at the rim of peritoneal pockets. (Chatman & Zbella, 1986; Martin, 1991; Sampson, 1927)

Goldstein (Goldstein, De Cholnoky, & Emans, 1980) documented that 47% of his 140 adolescent patients had endometriosis using the magnification of the laparoscope for a close-up view. Petechial and bleblike endometriotic lesions were the only finding in 20% of 65 adolescent patients. The more subtle lesions were found in 36% of 202 patients by Jansen. (Jansen & Russell, 1986) At the same time Jansen noted puckered bluish lesions in 85% of his patients. Using near-contact laparoscopy for better visualization of these lesions, Redwine found black lesions in 60% and other lesions in 66% of 137 patients. (Redwine, 1987a; Redwine, 1987b) Similar findings were noted by Martin with 60% of 166 patients having dark lesions and 65% having subtle lesions in a study of 20 descriptive types. (Martin, et al., 1989) Davis noted black or blue-black powder burn implants in 36% and subtle endometriosis in 64% of 66 patients. (Davis & Brooks, 1988)

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The magnification of the laparoscope and video monitoring systems are useful in increasing the resolution of lesions which are detected. The detection of lesions is related to the color contrast and resolution at lower powers. At present, detection and resolution are adequate for histological confirmation of:


Red lesions as small as 400 µ, (Stripling, et al., 1988a)


Clear lesions as small as 180 µ, (Martin, et al., 1989) and


Carbon particles as small as 40 µ.

However, Redwine has documented an undetected probable endometriotic lesion of 120 µ. (Redwine & Yocum, 1990) Nonvisualized lesions of 168 µ and 350 µ were seen in baboons. (D'Hooghe, Bambra, De Jonge, Machai, & Koninckx, 1995) Similar lesions in humans were noted with an average size of 313 µ in patients who had no other evidence of endometriosis. (Nisolle, Paindaveine, Bourdon, Berličre, Casanas-Roux, & Donnez, 1990) An undetected lesion of 400 µ in what appeared to be normal peritoneum at the base of pelvic pockets has also been noted. (Martin, 1991; Martin, 1992) At present, clinical resolution appears to be limited to 180 to 400 µ for endometriosis at laparoscopy.

Specimens of abnormal appearing tissue seen at second look laparoscopy following intra-abdominal CO2 laser surgery were analyzed in a search for atypical transformation in the remnant tissue. (Martin, et al., 1989; Martin & Vander Zwaag, 1987) Although atypical transformation was not noted, endometriosis was found in association with carbon from previous laser surgery and also in lesions that did not appear to be endometriosis. This is similar to other studies (Table 1)

Table 1.  Histologic confirmation of lesions of specific descriptions. (Jansen & Russell, 1986; Martin, et al., 1989; Moen & Halvorsen, 1992; Stripling, et al., 1988a; Stripling, et al., 1988b)

Author        Black   White  Red   Glandular    Subovarian    Yellow Brown    Pockets
                           Adhesions        Patches    
Jansen         ns        81%    81%       67%             50%                 47%             47%
Stripling     97%       91%    75%        ns                ns                  33%              ns
Stripling     98%       78%    92%        ns                ns                   40%             43%
Martin        94%       80%    75%       66%             39%                 22%             39%
Moen          76%        ns      57%        ns               16%                  ns               12%
ns = not stated

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When all patients had excision or biopsy of any abnormal appearing tissue the diagnosis of endometriosis increased (Table 2) from 42% in 1982 to 72% in 1988. (Martin, et al., 1989; Stripling, et al., 1988a) Furthermore, histologic confirmation of endometriosis increased from 62% in 1982 to 98% in 1988. (Martin, et al., 1989; Martin & Vander Zwaag, 1987) The largest increase appears to be due to the increased documentation of subtle lesions. This was associated with an increased awareness of these lesions and with use of the intrinsic accuracy of documentation using excisional techniques and the CO2 laser laparoscope.

Table 2.  Finding at laparoscopy. (Martin, et al., 1989; Stripling, et al., 1988a)

                                 1985      Early 1986  1986-87    1987-88
      Endometriosis      42%            47%           63%           71%
      "Dark" lesions         *              43%           53%           60%
      "Subtle" lesions      *              15%            58%          65%
      *No distinction made between "dark" and "subtle" in 1985.

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This increase in diagnosis and documentation of endometriosis also suggested that the diagnosis was missed in at least 7% of patients and identifiable lesions were not recognized in at least 50% of patients in early 1986. (Martin, et al., 1989) This is in spite of a 47% diagnosis rate associated with a 95% confirmation of submitted tissue in 1985. (Martin & Vander Zwaag, 1987) Many of the appearance findings occurred after the histologic confirmation rate was 97% or greater with tissue submitted on all endometriosis patients. (Martin, et al., 1989; Martin & Vander Zwaag, 1987) (Table 3)

Table 3.  Patients with specimens confirmed at laparoscopy. (Martin, et al., 1989; Martin & Vander Zwaag, 1987)

                                    1982     1984       1986      1988
      Patients sampled      13%      71%       100%     100%
      Specimens positive   62%      91%        97%       98%

In the same period of time, a study of 55 physicians showed that endometriosis was not documented in 14% to 59% of cases. (Martin, Ahmic, El-Zeky, Vander Zwaag, Pickens, & Cherry, 1990) (Table 4) Endometriosis was most commonly missed when it was obscured by adhesions, deep fibrosis, myomata, functional cysts, carbon and psammoma bodies. (Martin, et al., 1990; Martin, et al., 1989) This is similar to the Johns Hopkins Hospital experience where 35.5% of suspected cases were not confirmed and 30.6% of histologically positive cases were not noted at surgery. (Scott & TeLinde, 1950) 

Table 4.  Histologic confirmation related to physician case load in 1986.
Martin, et al., 1990

      Case load        Number        Sensitivity      Predictive
                          of Physicians                          Positivity

      5 or less              31                 41%                57%
      6 to 11                14                 54%                78%
      12 to 26                9                 73%                74%
      127                       1                 86%                 99%  

These data are compatible with Fallon's conclusion that experience creates uncertainty. (Fallon, Brosnan, Manning, Moran, Meyers, & Fletcher, 1950)

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bulletButtram, V. C., & Reiter, R. C. (1985). Endometriosis. In V. C.
bulletButtram & R. C. Reiter (Eds.), Surgical Treatment of the Infertile Female (pp. 89-147). Baltimore: Williams & Wilkins.
bulletChatman, D. L., & Zbella, E. A. (1986). Pelvic peritoneal defects and endometriosis: further observation. Fertil Steril, 46, 711-714.
bulletD'Hooghe, T. M., Bambra, C. S., De Jonge, I., Machai, P. N., & Koninckx, P. R. (1995). A serial section study of visually normal posterior pelvic peritoneum from baboons (papio cynocephalus, papio anubis) with and without spontaneous minimal endometriosis. Fertil Steril, 63, 1322-1325.
bulletDavis, G. D., & Brooks, R. A. (1988). Excision of pelvic endometriosis with the carbon dioxide laser laparoscope. Obstet Gynecol, 72, 816-819.
bulletDmowski, W. P. (1984). Pitfalls in clinical, laparoscopic and histologic diagnosis of endometriosis. Acta Obstet Gynecol Scan (Suppl), 123, 61-66.
bulletDmowski, W. P., Lesniewicz, R., Rana, N., Pepping, P., & Noursalehi, M. (1997). Changing trends in the diagnosis of endometriosis: a comparative study of women with pelvic endometriosis presenting with chronic pelvic pain or infertility. Fertil Steril, 67, 238-43.
bulletFallon, J., Brosnan, J. T., Manning, J. J., Moran, W. G., Meyers, J., & Fletcher, M. E. (1950). Endometriosis: a report of 400 cases. Rhode Island Med J, 33, 15-23.
bulletGoldstein, D. P., De Cholnoky, C., & Emans, S. J. (1980). Adolescent endometriosis. J Adol Health Care, 1, 37-41.
Haney, A. F. (1987). Endometriosis: pathogenesis and pathophysiology. In E. A. Wilson (Eds.), Endometriosis (pp. 23-52). New York: Alan R Liss.
bulletHulka, J. F. (1985). Special techniques. In J. F. Hulka (Eds.), Textbook of Laparoscopy (pp. 75-77). Orlando: Grune and Stratton.
bulletJansen, R. P. S., & Russell, P. (1986). Nonpigmented endometriosis: clinical, laparoscopic, and pathologic definition. Am J Obstet Gynecol, 155, 1154-1159.
bulletKirshon, B., Poindexter, A. N., & Fast, J. (1989). Endometriosis in multiparous women. J Reprod Med, 34, 215-217.
bulletKoninckx, P. R., Ruttinen, L., Seppala, M., & Cornillie, F. J. (1992). CA-125 and placental protein 14 concentrations in plasma and peritoneal fluid of women with deeply infiltrating pelvic endometriosis. Fertil Steril, 57, 523-530.
bulletMartin, D. C. (1991). Laparoscopic Appearance of Endometriosis. First Revision. Color Atlas (Second ed.). Memphis: Resurge Press. 
bulletMartin, D. C. (1992). Laparoscopic excision of infiltrating pelvic endometriosis. In A. Levensohn (Eds.), OB-GYN Illustrated Slingerlands, New York: LTI Medica (Upjohn).
bulletMartin, D. C., Ahmic, R., El-Zeky, F. A., Vander Zwaag, R., Pickens, M. T., & Cherry, K. (1990). Increased histologic confirmation of endometriosis. J Gynecol Surg, 6, 275-279.
bulletMartin, D. C., Hubert, G. D., Vander Zwaag, R., & El-Zeky, F. A. (1989). Laparoscopic appearances of peritoneal endometriosis. Fertil Steril, 51, 63-67.
bulletMartin, D. C., & Vander Zwaag, R. (1987). Excisional techniques for endometriosis with the CO2 laser laparoscope. J Reprod Med, 32, 753-758.
bulletMoen, M. H., & Halvorsen, T. B. (1992). Histologic confirmation of endometriosis in different peritoneal lesions. Acta Obstet Gynecol Scand, 71, 337-342.
bulletMurphy, A. A., Green, W. R., Bobbie, D., Dela Cruz, Z. C., & Rock, J. A. (1986). Unsuspected endometriosis documented by scanning electron microscopy in visually normal peritoneum. Fertil Steril, 46, 522-524.
bulletNisolle, M., Paindaveine, B., Bourdon, A., Berličre, M., Casanas-Roux, F., & Donnez, J. (1990). Histologic study of peritoneal endometriosis in infertile women. Fertil Steril, 53, 984-988.
bulletRedwine, D. B. (1987a). Age-related evolution in color appearance of endometriosis. Fertil Steril, 48, 1062-1063.
bulletRedwine, D. B. (1987b). The distribution of endometriosis in the pelvis by age groups and fertility. Fertil Steril, 47, 173-175.
bulletRedwine, D. B., & Yocum, L. B. (1990). A serial section study of visually normal pelvic peritoneum in patients with endometriosis. Fertil Steril, 54, 648-651.
bulletSampson, J. A. (1927). Peritoneal endometriosis due to menstrual dissemination of endometrial tissue into the peritoneal cavity. Am J Obstet Gynecol, 14, 422-469.
bulletScott, R. B., & TeLinde, R. W. (1950). External endometriosis - the scourge of the private patient. Ann Surg, 131, 697 - 720.
bulletSteingold, K. A., Cedars, M., Lu, J. K. H., Randle, D., Judd, H. L., & Meldrum, D. R. (1987). Treatment of endometriosis with a long-acting gonadotropin-releasing hormone agonist. Obstet Gynecol, 69, 403-411.
bulletStripling, M. C., Martin, D. C., Chatman, D. L., Vander Zwaag, R., & Poston, W. M. (1988a). Subtle appearance of pelvic endometriosis. Fertil Steril, 49, 427-431.
bulletStripling, M. C., Martin, D. C., & Poston, W. M. (1988b). Does endometriosis have a typical appearance? J Reprod Med, 33, 879-884.
bulletVernon, M. W., Beard, J. S., Graves, K., & Wilson, E. A. (1986). Classification of endometriotic implants by morphologic appearance and capacity to synthesize protaglandin F. Fertil Steril, 46, 801-806.
bulletWild, R. A., & Wilson, E. A. (1987). Clinical presentation and diagnosis. In E. A. Wilson (Eds.), Endometriosis (pp. 53-77). New York: Alan R Liss, Inc.
bulletWilliams, T. J., & Pratt, J. H. (1977). Endometriosis in 1,000 consecutive celiotomies: incidence and management. Am J Obstet Gynecol, 129, 245-250.

Adapted from "Recognition of Endometriosis" in
Laparoscopic Appearance of Endometriosis, Lecture Supplement
Martin DC (ed), Resurge Press, Memphis, (c)1991

The color illustrations that accompanied this paper are in the Color Atlas.

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