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Endometrial implants have many appearances:

  • the classical "powder-burn" or blueberry lesion
  • white lesions that mimic scar tissue
  • clear or slightly brown-colored papillary lesions
  • strawberry or flame-like lesions which are recently-developed and very hormonally active
  • peritoneal pockets which most often contain endometrial implants
  • deep culdesac nodules before and after laparoscopic excision
Click on a photo below to view a larger image.
Red Endometriosis

These"red" or "strawberry" implants of endometriosis are on the pelvic sidewall under the right ovary. They can be deep and invasive. Several of these implants were attached to the right ureter.
This photograph demonstrates the varied appearances of endometrial implants. Most of these implants are on the left pelvic sidewall, under the ovary. The white, black, and deep scarred implants should be excised to assure complete removal.
White Endometriotic Lesions
The outlined area contains both black endometrial implants (left side) and white scarred implants (right side). The entire area is hormonally active and should be excised. This area overlies the right side of the pelvis beneath the right ovary.
This photograph demonstrates implants of endometriosis with both black and white appearances. These implants are overlying the bladder.

Peritoneal Pockets


Peritoneal pockets or "windows" are deep pockets or sacs that most commonly are found in the area behind the uterus. They look like holes in the peritoneum and are often ignored. These pockets sometimes are 1 to 3 inches deep and usually have large areas of endometriosis hidden deep within.

Unless the pocket is opened and inspected, these implants will be missed. Once opened, the pocket and the endometriosis it contains are excised. It is theorized that these pockets may be the precursor for development of the deep nodules of endometriosis we commonly see in these same areas.

Black Endometriosis Before and After Excision

Deep culdesac endometriosis producing dysparunea (painful intercourse)
Closeup of the endometriotic nodules
The same area after laparoscopic excision of the endometriotic implants

Deep Culdesac Nodule of Endometriosis


Before laparoscopic excision
This nodule was attached and involved the rectosigmoid colon and left ureter. Because of its location, it caused severe pain with intercourse (dysparunea).


After laparoscopic excision
The nodule has been dissected off the colon and left ureter before it was removed.


This series of photographs demonstrates the appearance of deep implants of endometriosis in the "posterior culdesac" (the area behind the uterus and above the rectum.

The closeup view shows the involved area in more detail and clearly demonstrates the advantage of magnification that laparoscopy affords. The extent and depth of these implants could easily be missed at laparotomy, when the surgeon is operating without the benefit of magnification.

Clear, Non-Pigmented and Brown Endometriosis

Clear implants of endometriosis have the appearance of drops of water resting on the surface of the pelvic organs. These lesions may also have a slightly red or brown pigmentation. The endometriosis implants in this photograph are located in the deep culdesac behind the uterus.

Black and white endometriosis
Bowel Endometriosis