Unresolved challenges in endometriosis: diagnostic delay, disease progression and recurrence

Endometriosis is a chronic, systemic, and neuroinflammatory condition that affects approximately 10% of women of reproductive age. Despite its high prevalence, major gaps remain in diagnosis, understanding of disease progression, and recurrence prevention. Diagnosis is often delayed due to disease heterogeneity, nonspecific symptoms, and frequent overlap with other pain syndromes or coexisting adenomyosis. Transvaginal ultrasound and MRI, now increasingly standardized, have improved lesion detection and mapping. However, broader integration of complementary tools such as clinical scoring systems and molecular biomarkers, including salivary microRNAs, is still underway. Evidence suggests that endometriosis may progress in lesion depth and systemic impact, potentially leading to neuropathic pain or, rarely, malignant transformation. Recurrence rates after conservative surgery remain high, yet long-term hormonal treatment significantly reduces this risk. In this narrative review, we highlight that endometriosis is not a uniform disease but a spectrum of clinical entities requiring individualized management. Addressing these unresolved challenges through improved diagnostic tools and tailored long-term care strategies is critical to limiting progression, preventing recurrence, and improving patient outcomes.