American College of Obstetricians and Gynecologists (ACOG) Diagnosis of Endometriosis Guidelines - Key Takeaways
Amy Gildner, PT, MSc PT
Pelvic Floor Physiotherapist
Endometriosis has long been one of the most undertreated and misunderstood conditions in gynecology. Diagnostic delay is a significant issue in endometriosis care, drastically affecting individual’s quality of lives and allowing disease progression, with patients waiting an average of 4-11 years from the onset of symptoms to receipt of a diagnosis (American College of Obstetricians & Gynecologists, 2026). The 2026 guidelines from the American College of Obstetricians and Gynecologists (ACOG) marks a major shift in how clinicians are encouraged to recognize and diagnose endometriosis to address this gap in care. This renewed focus moves away from a delayed, surgery-dependent diagnosis towards earlier and more patient-centered care.
Key Takeaways
Symptom-based diagnosis rather than surgical.
Traditionally, endometriosis has required a surgical confirmation via laparoscopy for a formal diagnosis. ACOG now recommends that a clinical diagnosis, made through a symptom-based assessment and physical examination be used to initiate medical treatment. This allows providers to start treatment earlier, without waiting for surgery, and allows patients to be provided with symptom relief sooner.
Full recognition of the spectrum of endometriosis symptoms.
The new guidelines place an emphasis on the diverse presentation of endometriosis symptoms, and encourage a suspected diagnosis when patients report chronic pelvic pain, painful periods, pain with intercourse, pain or irregular bowel or bladder function, and infertility. The guidelines acknowledge that not all symptoms will be cyclical and linked to a menstrual cycle.
Imaging is helpful but not everything.
While the guidelines state that surgery is no longer required for a diagnosis, they suggest that imaging, particularly ultrasound as a first-line option and an MRI for suspected deep endometriosis, are helpful for evaluation. However, it is important to remember that imaging is not perfect, and some endometriosis lesions will be undetectable, therefore a negative scan does not rule out endometriosis.
Diagnostic laparoscopy is useful despite negative imaging.
Even if the results of a subjective and physical assessment and imaging are negative, diagnostic laparoscopy can be considered to confirm the diagnosis. During the laparoscopy, a biopsy of suspected lesions should be taken to provide histologic confirmation of endometriosis, however, even a negative histopathologic result does not exclude the possibility of endometriosis.
Treat during diagnosis.
During a diagnostic laparoscopy, suspected endometriosis lesions should be treated at to prevent the requirement for additional surgery, and focus on patient-centered care.
Systems level changes must occur to address barriers to a timely diagnosis.
The recommendations identified a range of factors that contribute to diagnostic delays, some of which are attributable to the disease itself, such as the variability in symptoms, and others involve inadequate training of clinicians in the recognition of endometriosis. The guidelines highlighted research that showed a dismissal, normalization, or misattribution of patient symptoms by clinicians, resulting in underdiagnoses, misdiagnosis, or delayed referrals for specialist care. Recommendations to facilitate earlier diagnosis include:
Enhanced medical education and training on endometriosis care support;
The use of a patient-centered care approach by validating patient symptoms and experiences, demonstrating sensitivity, and communicating clear and accurate information about endometriosis;
The shift to symptom-based clinical diagnosis;
Raising public awareness to mitigate endometriosis stigma and encourage patients to seek care sooner;
Further research to fully understand the pathophysiology of endometriosis and validate noninvasive methods to accurately diagnose.
ACOG’s 2026 guideline reframes endometriosis as a condition that should be recognized earlier, diagnosed based on symptoms, and managed collaboratively with the patients and other healthcare professionals. Patients should not need to wait years to undergo surgery to obtain a diagnosis and start treatment for their endometriosis.