A Better Path to Endo Answers
Should Start With Listening
How The Wellness Lounge is building a more thoughtful, less invasive path to answers
Painful periods are common. Period pain that repeatedly disrupts work, sleep, relationships, or daily life deserves a closer look.
Endometriosis affects an estimated 10% of women of reproductive age worldwide, yet the World Health Organization reports that diagnosis still takes four to twelve years on average. Clinicians estimate many more women may be effected but are never diagnosed due to dismissal from physicians. During that time, patients may be told their symptoms are normal, receive an inconclusive scan, or feel that surgery is the only way to find out what is happening. We believe there is a better place to begin: with the patient’s story.
At The Wellness Lounge, we are developing a stepwise approach to suspected endometriosis. It begins with a thorough provider evaluation and basic labs when appropriate. For patients whose symptoms suggest endometriosis, we are preparing to offer a saliva based test. Depending on the individual and the results, we may also recommend pelvic MRI interpreted by a radiologist experienced in gynecologic conditions. Each step should answer a question and help the patient make an informed decision about what comes next.
First, we look at the whole symptom pattern
Endometriosis does not present the same way in every person. Severe menstrual cramps may be the most obvious symptom, but the pattern can also include pelvic pain between periods, pain with sex, painful bowel movements or urination, bloating, fatigue, heavy bleeding, or difficulty becoming pregnant. Some symptoms change predictably with the menstrual cycle; others do not. Additionally, many patients may not present with classic symptoms associated with pain, but demonstrate other indications of inflammation.
A provider should have time to ask when symptoms occur, how they have changed, what has already been tried, and what they prevent the patient from doing. They should also develop a detailed history of the woman’s experience since beginning to menstruated. At The Lounge we also review menstrual and reproductive history, prior imaging, family history, medications, and other conditions that could contribute to pelvic pain or bleeding. A previous “normal” test matters, but it does not erase a persistent symptom pattern.
We may start with basic labs based on that history. For example, a complete blood count and iron studies can help assess heavy bleeding and fatigue. Other testing may help investigate possible alternative or overlapping conditions. These labs do not diagnose or rule out endometriosis, they help us understand the patient’s health while we investigate the source of symptoms.
An emerging saliva test may add another piece of evidence
When endometriosis is suspected, we are preparing to offer a saliva test that measures a pattern of microRNAs: small molecules involved in regulating gene activity. Research into this test is one of the most promising developments in the search for a less invasive diagnostic pathway.
In a 2025 validation study, the saliva microRNA signature had 97.3% sensitivity and 94.1% specificity in the study population. Sensitivity describes how often a test identifies people who have the condition; specificity describes how often it correctly identifies people who do not. Earlier validation research also reported high performance. These findings are why we are excited to make this option available.
In a separate 2026 evaluation at an endometriosis center involving a highly selected surgical population, researchers reported 78% sensitivity and 33% specificity. That result does not erase the larger validation study, but it shows why a saliva result should be interpreted alongside symptoms and imaging, and why ongoing independent evaluation matters.
A saliva test also cannot tell us exactly where lesions are, how deeply they involve nearby structures, or whether another condition is contributing to pain. A positive result can strengthen the case for further evaluation. A negative result should not automatically close the investigation when the history remains concerning.
We see a 97% sensitivity as a HUGE win to patients who have been waiting for an alternative to the existing methods of diagnosis, as endometriosis goes undetected and undiagnosed for YEARS for many women due to negative conclusions on a transvaginal ultrasound.
Next, Imaging
For some patients, the next useful question is anatomical: Is there visible disease, and where is it? Depending on the person’s symptoms, examination, test results, and goals, we may recommend a pelvic MRI using an endometriosis focused protocol, interpreted by a radiologist with experience in gynecologic disease.
MRI can help identify ovarian endometriomas and some forms of deep endometriosis. It can also help map disease near the bowel, bladder, or other pelvic structures when that information would affect a specialist referral or treatment decision. The quality of the scan protocol and the reader’s experience matter.
When imaging would help clarify a patient’s symptoms, we prefer a pelvic MRI with an endometriosis focused protocol, interpreted by a radiologist experienced in gynecologic conditions because the success rate of detection is in the 90%+ while data on transvaginal ultrasound is mixed and not as strong. MRI gives us a broad view of the pelvis and can help map deep disease across multiple areas, particularly when bowel or bladder involvement is a concern. It also avoids an internal exam, which some patients find painful or would prefer to avoid.
This is a preference based on the information and experience we want for our patients, rather than a claim that MRI detects every form of endometriosis better: a specialist performed transvaginal ultrasound can be highly effective for ovarian endometriomas and some deep lesions. However, neither scan reliably rules out superficial endometriosis, so a normal result will never end our investigation when a patient’s symptoms remain concerning. That is why we would never interpret a scan in isolation. If a patient’s symptoms continue to strongly suggest endometriosis, the conversation continues even when imaging is clear.
Typical Disease Diagnosis progression
For many patients, the search for answers begins with a transvaginal ultrasound. The scan may be reported as normal even when endometriosis is present, particularly if the disease is superficial. Too often, that result becomes the end of the conversation: symptoms persist, but the possibility of endometriosis is set aside. Some patients spend years seeking another evaluation before laparoscopy is discussed.
Laparoscopy can be valuable. It allows a specialist to look for lesions, potentially remove them, and examine tissue. But when its primary purpose is to find out whether endometriosis is present, a patient may undergo an invasive procedure without knowing what it will reveal. Some finally receive an explanation for years of symptoms; others have no endometriosis found and still need answers. In one study of patients undergoing laparoscopy for chronic pelvic pain without a prior diagnosis or ultrasound finding, endometriosis was confirmed in about half.
We believe our patients deserve a more informative path before reaching that decision: careful assessment, an honest explanation of what a normal scan cannot rule out, and access to appropriate testing and specialist care. Surgery should be a considered option, not the price of having persistent symptoms taken seriously.
Type and stage are different questions
As results come together, we want to understand what form of disease may be present and how that information affects care. Three commonly described forms of endometriosis are:
Superficial peritoneal endometriosis: lesions on the lining of the pelvic cavity. These can be difficult to see on imaging.
Ovarian endometrioma: an endometriosis associated cyst involving an ovary.
Deep endometriosis: disease extending beneath the tissue surface, sometimes involving structures near the bowel or bladder.
More than one form can occur in the same person.
These forms are often confused with the four surgical stages of endometriosis, which range from minimal (stage I) to severe (stage IV). The stages describe the extent of disease observed during surgery. Neither a saliva result nor an MRI can reliably assign a surgical stage. Stage also does not neatly predict how much pain a person experiences. Our immediate goal is to understand the patient’s symptoms, assess any visible disease, and identify the next decision that would meaningfully help them.
Where does surgery fit?
Laparoscopy can allow a surgeon to see and remove suspected lesions and obtain tissue for examination. It can be an important diagnostic and treatment option. We want patients who may benefit from surgery to have access to an experienced specialist and a clear discussion of its potential benefits and risks.
What we challenge is the idea that a patient must start with surgery to have their symptoms believed or to begin care. Current guidance also supports a clinical and imaging based evaluation rather than automatically making laparoscopy the first step for everyone.
For a patient with persistent symptoms, complex disease on imaging, unsuccessful treatment, or a reason to consider removal of lesions, a surgical consultation may be the right next step. For another patient, a careful clinical evaluation and a plan to manage symptoms while continuing the investigation may be more appropriate. The decision should be informed by the patient’s health and goals, including whether pregnancy is desired.
Additionally, when a patient decides to consider laparoscopy, we refer to surgeons trained in Surgical NaProTECHNOLOGY. We prefer this approach because it emphasizes treating disease found during surgery while paying close attention to the uterus, ovaries, fallopian tubes, and the patient’s fertility goals. A surgical consultation gives the patient a chance to discuss what the surgeon plans to do if endometriosis is found, the potential benefits and risks, and whether surgery fits their goals. We’ll share more in a future article about Surgical NaProTECHNOLOGY, the questions we encourage patients to ask, and how we make referrals.
Our goal: useful answers sooner
The long delay associated with endometriosis is not something patients should simply have to accept. A careful history, appropriate basic testing, emerging saliva diagnostics, and thoughtfully selected imaging can give us more ways to investigate symptoms before considering an invasive procedure.
No single test has every answer. Our commitment is to explain what each result means, what it cannot tell us, and what choices remain. Patients deserve a path forward even when an initial test is inconclusive.
We will take a deeper look on our Substack at the saliva test research, how to interpret sensitivity and specificity, what specialized MRI and ultrasound can detect, and when surgery may still offer the most useful answers.
References
World Health Organization. Endometriosis. Updated October 15, 2025.
Bendifallah S, et al. “Validation of a Saliva Micro–RNA Signature for Endometriosis.” NEJM Evidence. 2025. doi:10.1056/EVIDoa2400195.
Bendifallah S, et al. “Validation of a Salivary miRNA Signature of Endometriosis.” 2023.
Ormos M, et al. “Salivary microRNA testing for endometriosis: clinical evaluation in an endometriosis center.” European Journal of Obstetrics & Gynecology and Reproductive Biology. 2026. doi:10.1016/j.ejogrb.2026.115341.
Becker CM, et al. “ESHRE guideline: endometriosis.” Human Reproduction Open. 2022.
American College of Obstetricians and Gynecologists. Diagnosis of Endometriosis: Clinical Practice Guideline. 2026.