An International Terminology for Endometriosis, 2021

The Impact of Evolving Endometriosis Guidelines on Diagnosis and Observational Health Studies

STUDY QUESTION

Do recent changes in European Society of Human Reproduction and Embryology (ESHRE) clinical guidelines result in more comprehensive diagnosis of women with endometriosis?

SUMMARY ANSWER

The latest shift in clinical guidelines results in diagnosis of more women with endometriosis but current ESHRE diagnostic criteria do not capture a sizable percentage of women with the disease.

WHAT IS KNOWN ALREADY

Historically, laparoscopy was the gold standard for diagnosing endometriosis, a complex gynecological condition marked by a heterogeneous set of symptoms that vary widely among women. More recently, changes in clinical guidelines have shifted to incorporate imaging-based approaches such as transvaginal sonography and magnetic resonance imaging.

STUDY DESIGN SIZE DURATION

Retrospective, observational cohort study of women aged 15-49 years diagnosed with endometriosis in the United States (US) between January 1, 2013, and December 31, 2023.

PARTICIPANTS/MATERIALS SETTING METHODS

Data sources include US insurance claims data from the Merative™ MarketScan® Commercial Database (CCAE), Merative™ MarketScan® Multi-State Medicaid Database (MDCD), Optum® de-identified Electronic Health Record dataset (Optum® EHR), and electronic health record (EHR) data from a large academic medical center in New York City (CUIMC EHR). To examine the potential impact of expanding clinical criteria for the diagnosis of endometriosis, we validated and compared five cohort definitions based on different sets of diagnostic guidelines involving combinations of surgical confirmation, diagnostic imaging, guideline-recognized symptoms, and other symptoms commonly reported among women with endometriosis. We performed pairwise comparisons between cohorts and applied Bonferroni corrections to account for multiple comparisons.

MAIN RESULTS AND THE ROLE OF CHANCE

We identified 491,048 women with a diagnosis of endometriosis across the CCAE, MDCD, Optum EHR, and CUIMC EHR datasets. Each cohort definition demonstrated strong positive predictive value (0.84-0.96), yet only 15-20% of cases were identified by all 5 cohort definitions. Women diagnosed with endometriosis based on imaging and symptoms were three years younger, on average, than women with a diagnosis based on surgical confirmation (mean age = 35 years [SD = 9] vs 38 years [SD = 8]; p<0.001). Women in cohorts based only on symptoms were two years younger than those based on surgery (36 years [SD = 8] vs 38 years [SD = 8]; p<0.001). More than one-fourth of cases presented with endometriosis-related symptoms but lacked surgical or imaging-related documentation required by ESHRE guideline criteria. Pain was reported among nearly all women with endometriosis. Abdominal pain and pain in the pelvis were the most prevalent (ranging from 69% to 90% of women in each cohort). Among approximately 2-5% of all endometriosis cases (14,795 total), women presented with pelvic and/or abdominal pain but none of the other symptoms noted in clinical guidelines.

LIMITATIONS REASONS FOR CAUTION

Our study has potential biases associated with documentation practices and secondary data use of insurance claims and EHR data. Further, the phenotyping algorithms used rely on clinical codes that do not necessarily capture all ESHRE diagnostic criteria for endometriosis and may not be generalizable to women with atypical presentation of endometriosis.

WIDER IMPLICATIONS OF THE FINDINGS

High positive predictive value among all five cohort definitions despite poor overlap among cases identified illustrates both the heterogeneous presentation of the disease and importance of expanding diagnostic criteria. For example, cohorts derived from updated guidelines identified younger patients at time of diagnosis. Women diagnosed based on imaging had higher rates of emergency room visits while patients diagnosed via laparoscopy had a larger number of hospitalizations. The substantial number of cases with pelvic and/or abdominal pain but none of the other symptoms noted in clinical guidelines underscores the continued need for improved access to timely and appropriate care, particularly among those with non-classical symptoms, different care-seeking patterns, or lack of available surgical intervention.

Causal Relationship Between Endometriosis, Female Infertility, and Primary Ovarian Failure Through Bidirectional Mendelian Randomization

Background

Endometriosis and its associated gynecological diseases such as female infertility and primary ovarian failure (POF), impose a long-term disease burden on women. This study aims to explore the causal relationships between these conditions through a two-sample bidirectional Mendelian randomization (MR) study.

Methods

We utilized large-scale GWAS data and conducted bidirectional MR analyses using methods such as Inverse Variance Weighted (IVW) and MR-Egger to assess the causal relationships between endometriosis and female infertility, POF, amenorrhoea, and oligomenorrhoea.

Results

MR analysis revealed significant causal relationships between endometriosis and female infertility (OR=1.430, 95% CI 1.306-1.567, P<0.01) as well as POF (OR=1.348, 95% CI 1.050-1.731, P=0.019). Reverse MR analysis indicated causal relationships between amenorrhoea (OR=1.076, 95% CI 1.009-1.148, P=0.026) and female infertility (OR=1.340, 95% CI 1.092-1.645, P<0.01) with endometriosis. Sensitivity analyses confirmed the robustness of these findings (heterogeneity: Q_pval>0.05, pleiotropy: pval>0.05).

Conclusion

This study suggested that managing endometriosis may help prevent conditions such as female infertility and POF, and vice versa. Future research is needed to confirm these findings in more diverse populations.

Research priorities of endometriosis patients and supporters in Aotearoa New Zealand

BACKGROUND

In New Zealand, an estimated 10% of women and people presumed female at birth have endometriosis, a disease characterised by the presence of tissue similar to the lining of the uterus, outside of the uterus.

AIMS

The purpose of this study was to characterise the research priorities of New Zealand endometriosis patients and their support networks in alignment with an Australian study. This will allow researchers to be able to ensure their research aligns with closing research gaps prioritised by those who directly experience the impacts of the disease.

METHODS AND MATERIALS

There were 1262 responses to an online Qualtrics survey advertised through Endometriosis New Zealand's social media accounts and mailing list to reach endometriosis patients and their support networks.

RESULTS

Overall, the highest research priorities for surgically or radiologically confirmed endometriosis patients, clinically suspected endometriosis patients, chronic pelvic pain patients, and their parents, partners, family members and friends were the management and treatment of endometriosis, followed by understanding endometriosis' cause, and improved capacity to diagnose endometriosis earlier. The key differences between the priorities of symptomatic participants and supporters were that symptomatic participants placed a significantly higher priority on understanding the cause of endometriosis, and supporters placed a significantly higher priority on improving the diagnosis of endometriosis.

CONCLUSIONS

There is alignment between the ranking of general research priority areas for endometriosis in Australasia, allowing for clear priorities for future research teams to structure their work around patient-centredness.

ACR Appropriateness Criteria® Endometriosis

Endometriosis is a common condition impacting individuals assigned female at birth. Though incompletely understood, the disorder is caused by endometrial-like tissue located outside of the endometrial cavity, associated with inflammation and fibrosis. Clinical presentation is variable, ranging from asymptomatic to severe pelvic pain and infertility. Treatment is determined by the patient's individualized goals and can include medical therapies to temporize symptoms or definitive surgical excision. Imaging is used to help diagnose endometriosis and for treatment planning. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Intra-operative and post-operative complications of endometriosis excision using the SOSURE approach - A single- surgeon retrospective series of 1116 procedures over 8 years

Background

Endometriosis surgery outcomes have been widely studied, yet heterogeneity in terminology and techniques persist.

Objectives

This study focuses on the perioperative outcomes of a single surgeon using the same structured approach (SOSURE: Survey & Sigmoid mobilisation, Ovarian mobilisation, Suspension of uterus and ovaries, Ureterolysis, Rectovaginal and pararectal space development, Excision of all visible disease) and adheres to the recent standardised terminology proposed by international gynaecological and endometriosis societies.

Materials and Methods

A quality improvement study was conducted retrospectively from January 2015 to January 2023. Data collection involved two databases: the National British Society for Gynaecological Endoscopy (BSGE) database and a more comprehensive locally kept database. The methodology also integrated four endometriosis staging systems.

Main outcome measures

Intra-operative and post-operative complication rates.

Results

Between 2015 and 2023, 1047 women underwent 1116 endometriosis procedures in various UK hospitals with S.K. as primary surgeon. Exclusions totalled 20 due to missing records and specific surgical criteria. The rate of major post-operative complications (Clavien-Dindo grade 3a and 3b) was 1.5% and minor post-operative complications (Clavien-Dindo grade 1 and 2) were seen in 13.8%. No Clavien-Dindo grade 4 or 5 complications were noted.

Conclusion

Our study has shown a low complication rate in endometriosis surgery, despite increasing complexity of surgical cases. This is likely attributed to the surgeon's learning curve, high surgical volume and adherence to a structured approach.

What's new?

Our study demonstrates the learning curve of a surgeon over the course of 8 years. This series involved more than 1000 patients and to our knowledge, is the first to report the complexity of the casemix using four different endometriosis staging systems.

Bladder Endometriosis: What do we know and what is left to find out? A narrative review

Bladder endometriosis accounts for 70-85% of urinary tract endometriosis cases. Urinary tract endometriosis occurs in approximately 1% of those living with endometriosis. Underlying aetiology and pathogenesis are not fully understood, but there are several plausible theories. As well as the typical pain symptoms, those with bladder endometriosis can experience several urinary tract symptoms. The manifestation of these symptoms can have complex pathways and processes. Imaging is accurate in the diagnosis of bladder endometriosis and clinicians should be mindful of the risk of silent kidney loss. Management should be guided by symptoms; both medical and surgical options are feasible. Surgical management offers potentially definitive treatment. Excisional surgery via bladder shave or partial cystectomy offers good improvement in symptoms with relatively low rates of serious complications and recurrence.

Radiology State-of-the-art Review: Endometriosis Imaging Interpretation and Reporting

Endometriosis is a common condition impacting approximately 190 million individuals and up to 50% of women with infertility globally. The disease is characterized by endometrial-like tissue located outside of the uterine corpus, which causes cyclical hemorrhage, inflammation, and fibrosis. Based on clinical suspicion or findings at routine transvaginal pelvic US or other prior imaging, dedicated imaging for endometriosis may be warranted with MRI or advanced transvaginal US. Deep endometriosis (DE) in the pelvis includes evaluation for stromal and fibrotic components and architectural distortion resulting from fibrosis and tethering. It is a disease requiring a compartment-based, pattern-recognition approach. MRI has the benefit of global assessment of the pelvis and is effective in assessing for features of malignancy and for evaluating extrapelvic locations. Transvaginal US has the advantage of dynamic maneuvers to assess for adhesions and may achieve higher spatial resolution for assessing the depth of bowel wall invasion. T1-weighted MRI evaluation increases the specificity of diagnosis by identifying hemorrhagic components, but the presence of T1 signal hyperintensity is not essential for diagnosing DE. Endometriosis is a disease with a broad spectrum; understanding the mild through advanced manifestations, including malignancy evaluation, is within the scope and breadth of radiologists' interpretation.

PARP-1, EpCAM, and FRα as potential targets for intraoperative detection and delineation of endometriosis: a quantitative tissue expression analysis

BACKGROUND

Endometriosis is a gynecological disease characterized by the presence of endometrial tissue in abnormal locations, leading to severe symptoms, inflammation, pain, organ dysfunction, and infertility. Surgical removal of endometriosis lesions is crucial for improving pain and fertility outcomes, with the goal of complete lesion removal. This study aimed to analyze the location and expression patterns of poly (ADP-ribose) polymerase 1 (PARP-1), epithelial cell adhesion molecule (EpCAM), and folate receptor alpha (FRα) in endometriosis lesions and evaluate their potential for targeted imaging.

METHODS

Gene expression analysis was performed using the Turku endometriosis database (EndometDB). By immunohistochemistry, we investigated the presence and distribution of PARP-1, EpCAM, and FRα in endometriosis foci and adjacent tissue. We also applied an ad hoc platform for the analysis of images to perform a quantitative immunolocalization analysis. Double immunofluorescence analysis was carried out for PARP-1 and EpCAM, as well as for PARP-1 and FRα, to explore the expression of these combined markers within endometriosis foci and their potential simultaneous utilization in surgical treatment.

RESULTS

Gene expression analysis revealed that PARP-1, EpCAM, and FOLR1 (FRα gene) are more highly expressed in endometriotic lesions than in the peritoneum, which served as the control tissue. The results of the immunohistochemical study revealed a significant increase in the expression levels of all three biomarkers inside the endometriosis foci compared to the adjacent tissues. Additionally, the double immunofluorescence analysis consistently demonstrated the presence of PARP-1 in the nucleus and the expression of EpCAM and FRα in the cell membrane and cytoplasm.

CONCLUSION

Overall, these three markers demonstrate significant potential for effective imaging of endometriosis. In particular, the results emphasize the importance of PARP-1 expression as a possible indicator for distinguishing endometriotic lesions from adjacent tissue. PARP-1, as a potential biomarker for endometriosis, offers promising avenues for further investigation in terms of both pathophysiology and diagnostic-therapeutic approaches.

Ultrasonographic characterization of parametrial endometriosis: a prospective study

OBJECTIVE

To study the ultrasonographic diagnostic accuracy and characteristics of parametrial endometriosis comprehensively.

DESIGN

This prospective study enrolled patients with suspected deep endometriosis (DE) scheduled for laparoscopic surgical treatment. Preoperative ultrasonographic examinations were performed following the International Deep Endometriosis Analysis criteria. This study aimed to evaluate the presence of parametrial endometriosis and its ultrasonographic characteristics, using surgical diagnosis as the reference standard. Additionally, indirect signs of DE and concomitant DE nodules associated with parametrial involvement were identified, assessing their predictive significance in the anterior, lateral, and posterior parametrial areas.

SETTING

Referral institution for endometriosis.

PATIENTS

Patients with suspected DE scheduled for surgical treatment.

INTERVENTIONS

Standardized preoperative ultrasonographic examination.

MAIN OUTCOME MEASURES

The diagnostic accuracy of transvaginal ultrasound in identifying parametrial endometriosis, including sensitivity and specificity, and the ultrasonographic characteristics of parametrial nodules, prevalence in distinct parametrial areas, and associations with indirect DE signs and concomitant DE nodules.

RESULTS

Surgical confirmation of parametrial nodules was observed in 105 of 545 patients (left, 18.5; right, 17.0%). Transvaginal ultrasound demonstrated a sensitivity of 77.1% (95% confidence interval, 68.0%-84.8%) and specificity of 99.1% (95% confidence interval, 67.7%-99.8%). Parametrial nodules typically exhibited characteristics such as a mild hypoechoic appearance (83.6%), starry morphology (74.7%), irregular margins (70.2%), and low vascularization. The posterior parametrial region was the most common location (52.2%), followed by the lateral (41.0%) and anterior (6.8%) parametrial regions. Concomitant DE nodules in the rectum (63.5%) and infiltrating the rectovaginal septum (56.5%) were significantly more prevalent in patients with parametrial involvement. Indirect DE signs, such as the ovaries fixed to the uterine wall (71.8%) and the absence of a posterior sliding sign (51.8%), were also more common in women with parametrial nodules. Hydronephrosis, although relatively uncommon in patients with parametrial involvement (8.2%), was largely detected in lateral parametrial nodules (70.0%).

CONCLUSIONS

This study represents a systematic ultrasonographic characterization of parametrial endometriosis. Specifically, it comprehensively assesses the diagnostic accuracy of transvaginal ultrasound in identifying parametrial involvement within a sizable cohort of patients with preoperative suspicion of DE.

CLINICAL TRIAL REGISTRATION NUMBER

NCT06017531.

Comparison of ovarian reserve after cystectomy of ovarian endometrioma by bipolar coagulation, suture method, or hemostatic sealants: An updated meta-analysis

AIM

The purpose of the study was to compare the ovarian reserve after cystectomy of ovarian endometrioma by bipolar coagulation, suture method, or hemostatic sealants (HSs).

METHODS

We performed a meta-analysis of studies in which post-cystectomy serum anti-Müllerian hormone (AMH) values were compared between bipolar coagulation and suture method or between bipolar coagulation and HSs. Through a literature search, we retrieved 14 articles which met inclusion criteria and were eligible for final analysis. The articles included 10 randomized trials, 3 prospective studies, and 1 retrospective study (n = 1435). The primary outcome was post-cystectomy serum AMH values.

RESULTS

Both bipolar coagulation and suture methods showed significantly lower post-cystectomy AMH values at 3, 6, and 12 months. However, post-cystectomy serum AMH values at 12 months were significantly higher in the suture method group compared to the bipolar coagulation (weighted mean difference [WMD]: -1.10, 95% confidence interval [CI]: -1.83, -0.38, p = 0.003, I2 = 89, n = 3). The suture method also showed a lower decline rate at 3 months post-cystectomy compared to the bipolar coagulation group (WMD: -25.13%, 95% CI: -49.56 to -0.70, p = 0.04, I2 = 95%, n = 2). Overall, pregnancy rates were similar between the two groups. Between the bipolar coagulation and HSs group, serum AMH values at 3 months post-cystectomy were similar (WMD: -0.46, 95% CI: -1.04 to 0.13, p = 0.13, I2 = 0%, n = 3). However, the HSs group showed a less decline rate at 3 months post-cystectomy compared to the bipolar coagulation group (WMD: -17.02%, 95% CI: -22.81, -11.23, p < 0.00001, I2 = 0%, n = 3).

CONCLUSIONS

Both the suture method and HSs may have potential benefits in the preservation of ovarian reserve over the bipolar coagulation method when cystectomy for ovarian endometrioma is performed.

Comparison of clinical and ultrasound examinations in assessing the parametria in patients with deep infiltrating endometriosis: a multicentre prospective study

RESEARCH QUESTION

How do clinical rectovaginal examination and transvaginal ultrasound examination perform in the diagnosis of parametrial infiltration in patients with endometriosis?

DESIGN

This was a multicentre prospective observational study. Patients with suspected deep endometriosis at clinical examination and/or at ultrasound evaluation and scheduled for surgery were included. Following multicentre multidisciplinary meetings, consensus was obtained on terms and methodology to define the parametrium at pelvic anatomy, ultrasound and surgery. Sensitivity, specificity, accuracy, and positive and negative likelihood ratios were calculated for clinical and ultrasound examinations with respect to surgery.

RESULTS

In total, 195 women were selected for the present study and 164 were included in the analysis. Ultrasound examination had good to high specificity (>80%) for all parameters, except the left lateral parametrium (78.8%). The sensitivity of ultrasound examination was good to high for fixity of the right and left ovaries, uterosacral ligaments, retrocervix and rectovaginal space; and low for the anterior and lateral parametria, vagina, bladder and bowel. Clinical examination had good to high specificity for fixity of the left ovary, anterior parametrium, right uterosacral ligament, retrocervix and vagina; and low specificity for fixity of the right ovary, lateral parametrium, left uterosacral ligament and rectovaginal space. The sensitivity of clinical examination was good for the uterosacral ligaments and rectovaginal space, and low for the remaining parameters.

CONCLUSION

Ultrasound examination provided good specificity for all the parameters, but sensitivity was low for the anterior and lateral parametria. Clinical examination provided good specificity for the anterior and posterior parametria, but sensitivity was low for the anterior and lateral parametria. Further prospective studies are needed to validate this methodology and confirm the results.

The Antigen-Processing Pathway via Major Histocompatibility Complex I as a New Perspective in the Diagnosis and Treatment of Endometriosis

Endometriosis is a debilitating gynecological disease defined as the presence of endometrium-like epithelium and/or stroma outside the uterine cavity. The most commonly affected sites are the pelvic peritoneum, ovaries, uterosacral ligaments, and the rectovaginal septum. The aberrant tissue responds to hormonal stimulation, undergoing cyclical growth and shedding similar to appropriately located endometrial tissue in the uterus. Common symptoms of endometriosis are painful periods and ovulation, severe pelvic cramping, heavy bleeding, pain during sex, urination and bowel pain, bleeding, and pain between periods. Numerous theories have been proposed to explain the pathogenesis of endometriosis. Sampson's theory of retrograde menstruation is considered to be the most accepted. This theory assumes that endometriosis occurs due to the retrograde flow of endometrial cells through the fallopian tubes during menstruation. However, it has been shown that this process takes place in 90% of women, while endometriosis is diagnosed in only 10% of them. This means that there must be a mechanism that blocks the immune system from removing endometrial cells and interferes with its function, leading to implantation of the ectopic endometrium and the formation of lesions. In this review, we consider the contribution of components of the Major Histocompatibility Complex (MHC)-I-mediated antigen-processing pathway, such as the ERAP, TAP, LMP, LNPEP, and tapasin, to the susceptibility, onset, and severity of endometriosis. These elements can induce significant changes in MHC-I-bound peptidomes that may influence the response of immune cells to ectopic endometrial cells.

Acupuncture for endometriosis: A systematic review and meta-analysis

Background

Current endometriosis treatments do not always provide symptom relief, with many using complementary approaches. This study examined the effectiveness of acupuncture on pain and quality of life in people with endometriosis.

Methods

Searches were conducted on Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Allied and Complementary Medicine Database (AMED) and Embase (Ovid), Epistemonikos, and Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCOhost) on 20 March 2023. Trials were included if they used penetrating acupuncture. Risk of bias was assessed with Cochrane RoB2 and GRADE for overall evidence certainty. Random-effects meta-analyses were undertaken, using Hedges' g or mean difference (MD) both with 95 % confidence intervals (CI).

Results

Six studies involving a total of 331 participants were included. Evidence for benefit was found for acupuncture compared to non-specific acupuncture on overall pelvic pain (g = 1.54, 95 % CI 0.92 to 2.16, 3 RCTs, n = 231, low certainty evidence, p<0.001), menstrual pain (g = 1.67, 95 % CI 1.23 to 2.12, 1 RCT, n = 106, moderate certainty evidence, p<0.001), and non-specified pelvic pain (MD -2.77, 95 % CI 2.15 to 3.38, 2 RCTs, n = 125, low certainty evidence, p<0.001), and compared to usual care on menstrual pain (g = 0.9, 95 % CI 0.15 to 1.64, 1 RCT, n = 19, very low certainty evidence, p = 0.02). Most studies reported low rates of adverse events.

Conclusion

Acupuncture treatment for endometriosis demonstrated clinically relevant improvements in pelvic pain and should be considered as a potential treatment intervention.

Study registration

PROSPERO ID: CRD42023408700.

The Musashi RNA-binding proteins in female cancers: insights on molecular mechanisms and therapeutic relevance

RNA-binding proteins have increasingly been identified as important regulators of gene expression given their ability to bind distinct RNA sequences and regulate their fate. Mounting evidence suggests that RNA-binding proteins are involved in the onset and progression of multiple malignancies, prompting increasing interest in their potential for therapeutic intervention.The Musashi RNA binding proteins Musashi-1 and Musashi-2 were initially identified as developmental factors of the nervous system but have more recently been found to be ubiquitously expressed in physiological tissues and may be involved in pathological cell behavior. Both proteins are increasingly investigated in cancers given dysregulation in multiple tumor entities, including in female malignancies. Recent data suggest that the Musashi proteins serve as cancer stem cell markers as they contribute to cancer cell proliferation and therapy resistance, prompting efforts to identify mechanisms to target them. However, as the picture remains incomplete, continuous efforts to elucidate their role in different signaling pathways remain ongoing.In this review, we focus on the roles of Musashi proteins in tumors of the female - breast, endometrial, ovarian and cervical cancer - as we aim to summarize current knowledge and discuss future perspectives.

Clavien-Dindo, comprehensive complication index and classification of intraoperative adverse events: a uniform and holistic approach in adverse event registration for (deep) endometriosis surgery

STUDY QUESTION

What is the additional value of the comprehensive complication index (CCI) and ClassIntra system (classification for intraoperative adverse events (ioAEs)) in adverse event (AE) reporting in (deep) endometriosis (DE) surgery compared to only using the Clavien-Dindo (CD) system?

SUMMARY ANSWER

The CCI and ClassIntra are useful additional tools alongside the CD system for a complete and uniform overview of the total AE burden in patients with extensive surgery (such as DE), and with this uniform data registration, it is possible to provide greater insight into the quality of care.

WHAT IS KNOWN ALREADY

Uniform comparison of AEs reported in the literature is hampered by scattered registration. In endometriosis surgery, the usage of the CD complication system and the CCI is internationally recommended; however, the CCI is not routinely adapted in endometriosis care and research. Furthermore, a recommendation for ioAEs registration in endometriosis surgery is lacking, although this is vital information in surgical quality assessments.

STUDY DESIGN SIZE DURATION

A prospective mono-center study was conducted with 870 surgical DE cases from a non-university DE expertise center between February 2019 and December 2021.

PARTICIPANTS/MATERIALS SETTING METHODS

Endometriosis cases were collected with the EQUSUM system, a publicly available web-based application for registration of surgical procedures for endometriosis. Postoperative adverse events (poAEs) were classified with the CD complication system and CCI. Differences in reporting and classifying AEs between the CCI and the CD were assessed. ioAEs were assessed with the ClassIntra. The primary outcome measure was to assess the additional value toward the CD classification with the introduction of the CCI and ClassIntra. In addition, we report a benchmark for the CCI in DE surgery.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 870 DE procedures were registered, of which 145 procedures with one or more poAEs, resulting in a poAE rate of 16.7% (145/870), of which in 36 cases (4.1%), the poAE was classified as severe (≥Grade 3b). The median CCI (interquartile range) of patients with poAEs was 20.9 (20.9-31.7) and 33.7 (33.7-39.7) in the group of patients with severe poAEs. In 20 patients (13.8%), the CCI was higher than the CD because of multiple poAEs. There were 11 ioAEs reported (11/870, 1.3%) in all procedures, mostly minor and directly repaired serosa injuries.

LIMITATIONS REASONS FOR CAUTION

This study was conducted at a single center; thus, trends in AE rates and type of AEs could differ from other centers. Furthermore, no conclusion could be drawn on ioAEs in relation to the postoperative course because the power of this database is not robust enough for that purpose.

WIDER IMPLICATIONS OF THE FINDINGS

From our data, we would advise to use the Clavien-Dindo classification system together with the CCI and ClassIntra for a complete overview of AE registration. The CCI appeared to provide a more complete overview of the total burden of poAEs compared to only reporting the most severe poAEs (as with CD). If the use of the CD, CCI, and ClassIntra is widely adapted, uniform data comparison will be possible at (inter)national level, providing better insight into the quality of care. Our data could be used as a first benchmark for other DE centers to optimize information provision in the shared decision-making process.

STUDY FUNDING/COMPETING INTERESTS

No funding was received for this study. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Factors associated with deep infiltrating endometriosis, adenomyosis and ovarian endometrioma

Introduction: To compare epidemiological features and clinical presentations of deep infiltrating endometriosis with endometrioma and adenomyosis, as well as to identify risk factors for the respective histologically confirmed conditions. Method: Patients undergoing index surgery at the National University Hospital, Singapore for endometriosis or adenomyosis over a 7-year period—from 2015 to 2021—were identified from hospital databases using the Table of Surgical Procedures coding. Social and epidemiological features of cases with histologically confirmed diagnoses of endometrioma only, adenomyosis only, and deep infiltrating endometriosis were compared. Significant variables from univariate analysis were entered into 3 binary multivariate logistic regression models to obtain independent risk factors for: deep infiltrating endometriosis versus endometrioma only, deep infiltrating endometriosis versus adenomyosis only, and adenomyosis only versus endometrioma only. Results: A total of 258 patients were included with 59 ovarian endometrioma only, 47 adenomyosis only, and 152 deep infiltrating endometrioses. Compared to endometrioma only, deep infiltrating endometriosis was associated with higher rates of severe dysmenorrhoea (odds ratio [OR] 2.80, 95% confidence interval [CI] 1.02–7.70) and out-of-pocket private surgical care (OR 4.72, 95% CI 1.85–12.04). Compared to adenomyosis only, deep infiltrating endometriosis was associated with a higher fertility desire (OR 13.47, 95% CI 1.01–180.59) and a lower body mass index (OR 0.89, 95% CI 0.79–0.99). In contrast, heavy menstrual bleeding was the hallmark of adenomyosis, being less common in patients with endometriosis. Conclusion: Deep infiltrating endometriosis is associated with severe dysmenorrhoea, pain related to urinary and gastrointestinal tracts, higher fertility desire and infertility rate. Patients with pain symptomatology and subfertility should be referred early to a tertiary centre with the capability to diagnose and manage deep infiltrating endometriosis. Keywords: Adenomyosis, deep infiltrating endometriosis, obstetrics and gynaecology, ovarian endometrioma, public health

Qualitative and quantitative features of deep endometriosis in contrast-enhanced ultrasound: An initial experience and literature review

PURPOSE

This research aims to present the findings of contrast-enhanced ultrasound (CEUS) in a series of patients with proven deep endometriosis (DE) and provide an updated literature review.

MATERIALS AND METHODS

Between January 2018 and October 2022, seven patients with DE lesions had their imaging and medical records retrospectively reviewed. Clinical data, recorded images of a standardized conventional B-mode ultrasound, and Sonovue® CEUS were interpreted by two blinded, independent, experienced radiologists in consensus. The enhanced characteristics of the DE lesion on CEUS were also assessed using VueBox® software quantitatively.

RESULTS

DE lesion appeared as irregular hypoechoic or heterogeneous on conventional ultrasound with dotted blood flow signal on color Doppler. Six of seven DE lesions showed heterogeneous hypo-enhancement in arterial phases. All the lesions showed a heterogeneous washout rapidly that began in the late arterial phase. In quantified analysis, the mean relative peak enhancement compared with adjacent tissue was 0.47±0.25.

CONCLUSION

Our findings and literature review suggested that CEUS could be a feasible and promising non-invasive modality for diagnosing DE.

Preoperative application of the Enzian classification for endometriosis (The cEnzian Study): A prospective international multicenter study

OBJECTIVE

To assess the diagnostic performance of preoperative application of the Enzian classification (cEnzian) using surgical findings as reference standard.

DESIGN

A prospective international non-interventional study.

SETTING

Twelve endometriosis centres in four European countries (Austria, Germany, Switzerland and Czech Republic).

POPULATION

1062 women with endometriosis surgery.

METHODS

Extent of endometriosis was preoperatively classified using the cEnzian classification based on gynaecological examination and/or transvaginal ultrasound (TVS) and/or magnetic resonance imaging (MRI). After subsequent surgery, the surgeon classified the intraoperative findings using the Enzian classification.

MAIN OUTCOME MEASURES

Sensitivity, specificity, PPV, NPV, LR⁺ , LR^- and accuracy were calculated. Conditional frequencies of intraoperative Enzian codings and the corresponding 95% confidence intervals were computed for each preoperative coding and visualised in plots.

RESULTS

Although overall consistency of cEnzian and Enzian was poor (35.14%, 95% confidence interval 32.26-38.03), high specificities and negative predictive values (NPVs) of the cEnzian compartments could be demonstrated. Looking at the individual parts of the Enzian classification, the poorest diagnostic performance was detected for compartment B and the highest PPVs were found for category 3 lesions (>3 cm), independent of the compartment.

CONCLUSIONS

Using the Enzian classification in a non-invasive setting is a useful tool providing us with an 'at a glance' summary of the diagnostic workup regarding deep endometriosis with high specificities and NPVs. An attempt to merge the two new endometriosis classification systems (#Enzian and AAGL 2021) seems reasonable taking into consideration the respective advantages of each other.

Strengths and limitations of diagnostic tools for endometriosis and relevance in diagnostic test accuracy research

Endometriosis is a chronic systemic disease that can cause pain, infertility and reduced quality of life. Diagnosing endometriosis remains challenging, which yields diagnostic delays for patients. Research on diagnostic test accuracy in endometriosis can be difficult due to verification bias, as not all patients with endometriosis undergo definitive diagnostic testing. The purpose of this State-of-the-Art Review is to provide a comprehensive update on the strengths and limitations of the diagnostic modalities used in endometriosis and discuss the relevance of diagnostic test accuracy research pertaining to each. We performed a comprehensive literature review of the following methods: clinical assessment including history and physical examination, biomarkers, diagnostic imaging, surgical diagnosis and histopathology. Our review suggests that, although non-invasive diagnostic methods, such as clinical assessment, ultrasound and magnetic resonance imaging, do not yet qualify formally as replacement tests for surgery in diagnosing all subtypes of endometriosis, they are likely to be appropriate for advanced stages of endometriosis. We also demonstrate in our review that all methods have strengths and limitations, leading to our conclusion that there should not be a single gold-standard diagnostic method for endometriosis, but rather, multiple accepted diagnostic methods appropriate for different circumstances. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Nieuwenhuizen K, Bronsgeest K, Rhemrev J, Smeets M, English J, Jansen F, Both S, Twijnstra A. Preoperative pain measurements in correlation to deep endometriosis classification with Enzian. Deep endometriosis classification in relation to pain

Background: Deep Endometriosis (DE) classification studies with Enzian never compared solitary (A, B, C, F), and combinations of anatomical locations (A&B, A&C, B&C, A&B&C), in correlation to pain. Therefore, the results of these studies are challenging to translate to the clinical situation. Objectives: We studied pain symptoms and their correlation with the solitary and combinations of anatomical locations of deep endometriosis lesion(s) classified by the Enzian score. Materials and Methods: A prospective multi-centre study was conducted with data from university and non-university hospitals. A total of 419 surgical DE cases were collected with the web-based application called EQUSUM (www.equsum.org). Main outcome measures: Preoperative reported numeric rating scale (NRS) were collected along with the Enzian classification. Baseline characteristics, pain scores, surgical procedure and extent of the disease were also collected. Results: In general, more extensive involvement of DE does not lead to an increase in the numerical rating scale for pain measures. However, dysuria and bladder involvement do show a clear correlation AUC 0.62 (SE 0.04, CI 0.54-0.71, p< 0.01). Regarding the predictive value of dyschezia, we found a weak, but significant correlation with ureteric involvement; AUC 0.60 (SE 0.04, CI 0.53-0.67, p< 0.01). Conclusions:TPain symptoms poorly correlate with anatomical locations of deep endometriosis in almost all pain scores, with the exception of bladder involvement and dysuria which did show a correlation. Also, dyschezia seems to have predictive value for DE ureteric involvement and therefore MRI or ultrasound imaging (ureter and kidney) could be recommended in the preoperative workup of these patients. What’s new? Dyschezia might have a predictive value in detecting ureteric involvement.

Endometriosis Classification Systems: An International Survey to Map Current Knowledge and Uptake

OBJECTIVE

In the field of endometriosis, several classification, staging and reporting systems have been developed, but do clinicians routinely use these classification systems, which system do they use and what are the clinicians' motivations?

DATA SOURCES

A cross-sectional study was performed to gather data on the current use of endometriosis classification systems, problems encountered and interest in a new simple surgical descriptive system for endometriosis. Of particular focus were three systems most commonly used: the Revised American Society for Reproductive Medicine (rASRM) classification, the Endometriosis Fertility Index (EFI), and the ENZIAN classification. Data were analysed by SPSS. A survey was designed using the online SurveyMonkey tool consisting of 11 questions concerning three domains-participants background, existing classification systems and intentions with regards to a new classification system for endometriosis. Replies were collected between 15 May and 1 July 2020.

METHODS OF STUDY SELECTION

na TABULATION, INTEGRATION AND RESULTS: The final dataset included the replies of 1178 clinicians, including surgeons, gynecologists, reproductive endocrinologists, fertility specialists and sonographers, all managing women with endometriosis in their clinical practice. Overall, 75.5% of the professionals indicate that they currently use a classification system for endometriosis. The rASRM classification system was the best known and used system, the EFI system and ENZIAN system were known by a majority of the professionals but used by only a minority. The lack of clinical relevance was most often selected as a problem with using any system. The findings of the survey suggest that clinicians worldwide are open to using a new classification system for endometriosis that can achieve standardized reporting, and is clinically relevant and simple. The findings therefore support future initiatives for the development of a new descriptive system for endometriosis and provide information on user expectations and conditions for universal uptake of such a system.

CONCLUSION

Even with a high uptake of the existing endometriosis classification systems (rASRM, ENZIAN and EFI), most clinicians managing endometriosis would like a new simple surgical descriptive system for endometriosis.

Endometriosis Is Undervalued: A Call to Action

Endometriosis is an inflammatory chronic pain condition caused by uterine tissue growing outside of the uterus that afflicts at least 11% of women (and people assigned female at birth) worldwide. This condition results in a substantial burden to these women, and society at large. Although endometriosis was first identified over 160 years ago, substantial knowledge gaps remain, including confirmation of the disease's etiology. Research funding for endometriosis is limited, with funding from bodies like the National Institutes of Health (NIH) constituting only 0.038% of the 2022 health budget—for a condition that affects 6.5 million women in the US alone and over 190 million worldwide. A major issue is that diagnosis of endometriosis is frequently delayed because surgery is required to histologically confirm the diagnosis. This delay increases symptom intensity, the risk of central and peripheral sensitization and the costs of the disease for the patient and their nation. Current conservative treatments of presumed endometriosis are pain management and birth control. Both of these methods are flawed and can be entirely ineffective for the reduction of patient suffering or improving ability to work, and neither addresses the severe infertility issues or higher risk of certain cancers. Endometriosis research deserves the funding and attention that befits a disease with its substantial prevalence, effects, and economic costs. This funding could improve patient outcomes by introducing less invasive and more timely methods for diagnosis and treatment, including options such as novel biomarkers, nanomedicine, and microbiome alterations.

Endometriosis classification systems: an international survey to map current knowledge and uptake

Background

In the field of endometriosis, several classification, staging and reporting systems have been developed and published, but there are no data on the uptake of these systems in clinical practice.

Objectives

The objective of the current study was to examine whether clinicians routinely use the existing endometriosis classification systems, which system do they use and what are the clinicians’ motivations?

Materials and Methods

A cross-sectional study was performed to gather data on the current use of endometriosis classification systems, problems encountered and interest in a new simple surgical descriptive system for endometriosis. Of particular focus were three systems most commonly used: the Revised American Society for Reproductive Medicine (rASRM) classification, the Endometriosis Fertility Index (EFI), and the ENZIAN classification. Data were analysed by SPSS. A survey was designed using the online SurveyMonkey tool consisting of 11 questions concerning three domains— participants’ background, existing classification systems and intentions with regards to a new classification system for endometriosis. Replies were collected between 15 May and 1 July 2020.

Main outcome measures

Uptake, feedback and future intentions.

Results

The final dataset included the replies of 1178 clinicians, including surgeons, gynaecologists, reproductive endocrinologists, fertility specialists and sonographers, all managing women with endometriosis in their clinical practice. Overall, 75.5% of the professionals indicate that they currently use a classification system for endometriosis. The rASRM classification system was the best known and used system, the EFI system and ENZIAN system were known by a majority of the professionals but used by only a minority. The lack of clinical relevance was most often selected as a problem with using any system. The findings of the survey suggest that clinicians worldwide are open to using a new classification system for endometriosis that can achieve standardised reporting, and is clinically relevant and simple.

Conclusions

Even with a high uptake of the existing endometriosis classification systems (rASRM, ENZIAN and EFI), most clinicians managing endometriosis would like a new simple surgical descriptive system for endometriosis.

What is new?

The findings therefore support future initiatives for the development of a new descriptive system for endometriosis and provide information on user expectations and conditions for universal uptake of such a system.

Hormonal, apoptotic, proliferative and inflammatory markers' expression in Desogestrel-treated women with ovarian endometriosis

Endometriosis is a relatively frequent pathology in gynecological practice. We performed an analysis to demonstrate the molecular changes that occur in endometriosis synthetic progestin-treated patients, hoping to sketch a possible pathophysiological pathway that will help us to better understand and treat this debilitating disease. We conducted a prospective study that included a group of 40 women, evaluated in our hospital between 2020-2021. We evaluated immunohistochemical tissue expression of estrogen receptor (ER), progesterone receptor (PR), B-cell lymphoma 2 (Bcl-2) protein, Ki-67, and serum levels of osteopontin (OPN) and vascular endothelial growth factor (VEGF) in patients with ovarian endometrioma with and without progestin treatment. Our study revealed that Desogestrel treatment increases OPN serum levels, PR and Bcl-2 tissue expression and reduces VEGF serum levels and Ki-67 tissue expression. The results we have obtained are very interesting because the serum levels of OPN seem to be more influenced by progestin treatment, than by endometriosis itself. The study we have conducted gives a molecular complex view of what endometriosis represents and on how Desogestrel treatment works.