Endometriosis is a prevalent gynecological disorder where tissue similar to the lining of the uterus grows outside the uterine cavity, often causing persistent pelvic pain, fertility issues, and disruptions in menstrual cycles Preoperative assessment, particularly through imaging, ‘role’ in diagnosis and management endometriosis. The aim of study was to ‘evaluate the histopathological findings of endometriosis and’ assess the accuracy of imaging modalities such as transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) in preoperative diagnosis.Methodology This cross-sectional study involved 80 women diagnosed with endometriosis who underwent surgical intervention at a Hayatabad Medical Complex, Peshawar. Histopathological evaluation confirmed the diagnosis, and preoperative imaging results were compared. Imaging modalities, including TVS and MRI, were assessed for their sensitivity and specificity in detecting various forms of endometriosis, such as endometriomas and deep infiltrating endometriosis (DIE). Data were analyzed ‘using chi-square tests to assess the association between’ recurrence rates and endometriosis type, as well as fertility restoration post-surgery. Results Histopathological findings confirmed that 50% of the cases were endometriomas and 50% were deep infiltrating endometriosis. MRI demonstrated a sensitivity of 90% and a specificity of 95%, outperforming TVS, which had a sensitivity of 85% and a specificity of 90%. Recurrence was noted in 18.75% of cases, with no ‘significant association between’ recurrence and type of endometriosis (p 0.252). Fertility restoration was achieved in 19% of patients post-surgery. Complications were minimal, occurring in 6.25% of cases. Conclusion The histopathological evaluation remains the gold standard for diagnosing endometriosis, but imaging, especially MRI, is invaluable for preoperative planning, particularly in complex cases like DIE. MRI showed superior sensitivity and specificity compared to TVS. Although surgery provides pain relief and improves fertility, recurrence remains a concern, emphasizing the need for long-term management strategies.