This leaflet is to help you understand what Deep Endometriosis of the Uterosacral Ligaments is, how does it happen, what tests you need and what are the long term implications of the diagnosis?

What is a deep endometriosis and how are the uterosacral ligaments involved?

Deep endometriosis (DE) is when endometrial-like tissue invades the organs either within or outside your pelvic cavity. It affects about 10-20% of endometriosis cases. The most common involved location is the uterosacral ligaments (USLs) with a prevalence of 20- 70%. The USLs are thick bands of connective tissue that help support the uterus. They travel from the base of the uterus to lower spine. Similar to other forms of endometriosis, deep endometriosis lesions can cause several symptoms related to their location, such as dysmenorrhea (painful menstruation), dyspareunia (pain during intercourse), dysuria (pain while urinating), dyschezia (constipation), chronic pelvic pain, and infertility. The involvement of USLs have been linked to chronic pelvic pain, dysmenorrhea (painful menstruation), and dyspareunia (pain during intercourse). Lastly, there’s a delay of about 7-10 years between the onset of first symptoms and clinical diagnosis of endometriosis.

How is deep endometriosis of the USLs diagnosed?


Historically, laparoscopy with histological confirmation was the most widely adopted method for diagnosing endometriosis. However, in recent years, the trend has shifted away from using laparoscopy primarily for diagnosis, with a preference for using it as a combined surgical confirmation and a treatment modality when endometriosis is detected. Typically, the DE nodules occur in the proximal aspect of the USLs and can be red, black, or white/clear. Laparoscopy is skill-dependent and is limited by poor visualization of the posterior compartment when there is severe disease.

Transvaginal Ultrasound (TVS)

TVS serves as a non-invasive diagnostic tool for endometriosis, including the DE of the USLs. If a patient is diagnosed with DE; the examination of USLs is crucial as they have been reported to be the most common site of DE. During the ultrasound examination, clinicians will look for irregular contour and hypoechoic (dark) areas, which are the irregular masses/nodules, as seen below. Clinicians will also ask patients about the site-specific tenderness which is whether they’re experiencing pain in their USLs during the scan.

What are the treatment/management options for DE of the USLs?

There is currently no known cure for endometriosis, and symptoms are managed by medical, surgical, and/ or self-management strategies. It is important to note that endometriosis is a whole-body inflammatory disease and treatment often involves a multimodal approach with the collaboration of different healthcare providers and specialists which is ultimately the patients’ decision to make.

List of potential questions to ask

  • What is the best treatment/management plan for my condition?
  • Where is the endometriosis located in my pelvis?
  • How can I make a decision for my treatment plan and what resources are available to me?
  • If I choose to pursue fertility-based treatments, what options are available to me?


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Deep Endometriosis of the Uterosacral Ligaments