UNMASK-Endo Protocol: Diagnosis and Management of Masked, Atypical and Extragenital Endometriosis

This protocol is intended for primary, secondary and tertiary care. It is based mainly on the ESHRE 2022 endometriosis guideline and NICE guideline NG73 (updated 2024).Diagnostic sections should also be cross-checked against ACOG Clinical Practice Guideline No. 11 (2026). Drugs, doses and regimens must follow product labels and localregulations. Sections 13–15 (the VIRA model and patient-facing communication) are the author’s framework and have not yet been validated in prospective studies. The protocol does not replace clinical judgment. “Masks of endometriosis” are situations in which the disease does not present with the classic combination of dysmenorrhea, dyspareunia, chronic pelvic pain and infertility. Instead it presents with symptoms of the bowel, urinary tract, nervous system, chest or surgical scars, or as “unexplained infertility”. Consequences: a diagnostic delay averaging 7–10 years, treatment of the wrong diagnosis, unnecessary operations and loss of ovarian reserve.Aims of the protocol:minimize the time to diagnosis;define disease extent (pelvic, deep, extragenital) before treatment;choose management by the dominant goal: pain or fertility;refer promptly to an expert centre when disease is deep or extragenital The UNMASK-Endo frameworkU — Unify: link symptoms to the menstrual cycle (Section 3).N — Name the mask: identify the organ-specific presentation (Section 4).M — Map the disease: history, examination, imaging, laboratory tests and laparoscopy when needed (Sections 5–6).A — Alert: recognize red flags and route urgently (Section 7).S — Stratify and treat: choose therapy by the dominant goal, pain or fertility, and by mask (Sections 8–12).K — Keep trust: psychological support, anti-dismissal practice, follow-up and referral (Sections 13–16)