Search Results (18)

Background: Current endometriosis classification systems have important limitations in accurately describing total disease burden and predicting clinical outcomes. Existing staging frameworks often fail to integrate adenomyosis and do not adequately distinguish between genital and extragenital disease involvement. The aim of this article was to introduce the AGCES (American & Global College of Endometriosis Specialists) classification system, a novel framework designed to provide a more comprehensive and clinically meaningful approach to staging endometriosis. Methods: The AGCES classification system was developed through an expert consensus process involving scientific members of the American & Global College of Endometriosis Specialists (AGCES), informed by extensive surgical experience on thousands of endometriosis surgeries, synthesis of published evidence on disease pathophysiology and anatomical distribution, and systematic analysis of the limitations of existing classification systems (rASRM, ENZIAN, AAGL, EFI). Results: The framework integrates adenomyosis as a component of endometriosis staging and separates genital and extragenital disease into independent staging categories. Disease burden is reported using three parallel components representing adenomyosis (A), genital endometriosis (G), and extragenital endometriosis (E). A standardized operative reporting template and digital implementation through web-based applications were also developed to support clinical use. Conclusions: The AGCES classification system introduces a novel approach to endometriosis staging by integrating adenomyosis and separating genital and extragenital disease components. This framework provides a more complete assessment of disease burden and has the potential to improve clinical documentation, surgical planning, and research standardization in endometriosis care. Full article

Background/Objectives: Endometriosis is a chronic inflammatory disease with a heterogeneous clinical presentation, in which pain represents the predominant symptom. The association between pain severity and intraoperative disease stage remains unclear, particularly with regard to the rASRM and #ENZIAN classifications. This study aimed to evaluate the relationship between pain intensity at different anatomical sites and the stage of endometriosis according to the rASRM and #ENZIAN systems. Methods: A total of 138 patients with advanced endometriosis undergoing surgical treatment between May 2024 and August 2025 were included. Pain intensity was assessed using a 10-point Numerical Rating Scale (NRS) for pelvic pain, pain during defecation, pain during micturition, and pain during or after sexual intercourse. The stage of endometriosis was evaluated intraoperatively according to the rASRM and #ENZIAN classifications. Non-parametric statistical tests and Spearman’s rank correlation coefficient were applied. A p-value < 0.05 was considered statistically significant. Results: No significant correlation was found between overall pelvic pain intensity and disease stage according to the rASRM classification. However, significant differences in pain during micturition were observed depending on rASRM stage (p = 0.004). In the #ENZIAN-based analysis, significant associations were identified between selected anatomical areas and specific pain symptoms, particularly pain during micturition, defecation, and sexual intercourse. Conclusions: Pain severity in advanced endometriosis does not consistently correlate with overall disease stage according to rASRM. The anatomical localization of lesions defined by the #ENZIAN classification may better reflect the type and distribution of pain symptoms. These findings should be interpreted in the context of a selected cohort of surgically treated patients with advanced disease and may not be generalizable to patients with milder or non-surgically managed endometriosis. Full article

Background: This study examines the impact of endometriosis on sexual function, focusing on disease localization, pain severity, and psychosocial factors. It integrates the rASRM and Enzian classification systems to explore anatomical contributions to sexual dysfunction. Methods: In a cross-sectional study, 102 patients with confirmed endometriosis completed an online evaluation. Of these, 77 had surgical and histological confirmation, and 25 had no prior surgery. Thirty-five participants were using hormonal therapy. Validated instruments assessed sexual function, pain intensity (VAS), and psychosocial variables. Analyses included univariate tests and multivariate logistic regression. Results: Deep infiltrating endometriosis involving the sacrouterine ligaments, cardinal ligaments, and pelvic sidewall (Enzian B) was associated with sexual dysfunction, highlighting the anatomical utility of the Enzian system. Surprisingly, those with sexual dysfunction reported lower pain scores (p = 0.024 *). In multivariate analysis (R² = 0.281), no individual factor, including Enzian B involvement or EHP scores, remained significant. No associations were found between sexual dysfunction and anxiety, depression, stress, or relationship satisfaction, though pain was inversely correlated with anxiety (p = 0.025 *). Conclusions: Sexual dysfunction in endometriosis appears multifactorial, not solely driven by lesion burden or pain. A multidisciplinary approach is recommended, addressing anatomical, psychological, and behavioral dimensions. Full article

Background: Endometrioma recurrence after laparoscopic cystectomy remains a clinical challenge in the long-term management of endometriosis. The Empressin Injection Technique (EIT), which involves the use of a vasopressin analog during surgery, may reduce recurrence by improving the completeness of cyst removal. This study aimed to evaluate the impact of the EIT on recurrence rates compared to standard cystectomy without Empressin. Methods: We conducted a retrospective case–control study of 263 patients who underwent laparoscopic cystectomy for unilateral or bilateral endometriomas between 2014 and 2024 at a tertiary endometriosis referral center. The patients were divided into two groups: EIT (n = 110) and control (n = 153). In the EIT group, 10 mL of diluted Empressin (1 mL in 100 mL NaCl 0.9%) was injected at the cyst capsule–ovarian cortex interface prior to stripping. Demographic and clinical variables were analyzed using descriptive statistics (chi-square test and the Mann–Whitney t-test) and logistic regression to identify factors associated with recurrence between the two groups. Results: No significant differences were found between the groups regarding age, BMI, #ENZIAN O score, or r-ASRM stage. No intraoperative or postoperative complications were reported. Recurrence was significantly lower in the EIT group (5.5%) compared to the control group (19.6%) (p = 0.001; OR 0.2, 95% CI: 0.08–0.55). Hormonal therapy was administered postoperatively in 69.1% of EIT patients and 62.5% of controls. Pregnancy rates were comparable between the groups. Repeat surgery for recurrence was required only in the control group (4.2%, p = 0.004). Conclusions: Use of Empressin during laparoscopic cystectomy significantly reduces endometrioma recurrence without adverse effects, particularly when combined with postoperative hormonal therapy. Full article

Background: Endometriosis is a chronic, estrogen-dependent inflammatory disease affecting up to 10% of women of reproductive age. It substantially impacts quality of life (QoL) through pelvic pain, infertility, and psychological distress. Increasing attention has been directed toward patient-reported outcomes and validated QoL instruments, which are essential for understanding the burden of disease and guiding individualized management. Materials and Methods: We performed a narrative review of the literature published in the last five years in PubMed, Scopus, Web of Science, and Cochrane Library, focusing on validated QoL instruments, fertility indices, and clinical outcomes after minimally invasive surgery (MIS) for deep infiltrating endometriosis (DIE). Discussions: The most widely used QoL instruments are the Endometriosis Health Profile-30 (EHP-30), Short Form-36 (SF-36), and EQ-5D, each providing multidimensional evaluation across physical, psychological, and social domains. Fertility-related prognosis is assessed with the Endometriosis Fertility Index (EFI), while staging of disease severity relies on rASRM and #ENZIAN classifications. Evidence from comparative and cohort studies suggests that both laparoscopic and robotic MIS can improve QoL and reproductive outcomes; however, the magnitude of benefit varies across studies, patient phenotypes, and follow-up periods. Conclusions: MIS is an increasingly used therapeutic option for DIE, with growing evidence of improvement in pain and QoL, but current data remain heterogeneous and do not uniformly support superiority over other approaches. Routine incorporation of validated QoL instruments and fertility indices into both clinical practice and research is essential to better stratify patients, support shared decision-making, and optimize long-term outcomes. Full article

Aim: The aim of the study was to synthesize validated patient-reported outcome measures (PROMs) for assessing health-related quality of life (HRQoL) in women with endometriosis and to outline their clinical implications. Methods: We conducted a narrative review of English-language literature indexed in PubMed, Scopus, Web of Science, and Cochrane Library, covering the period 2014–2024, with earlier seminal studies included where relevant. We focused on validated PROMs for QoL but also considered standardized tools such as the Endometriosis Fertility Index (EFI), rASRM, and #Enzian classifications, given their role in clinical interpretation and counseling. Findings: Generic instruments (SF-36, WHOQOL-BREF, EQ-5D), disease-specific tools (EHP-30, EHP-5), and fertility-related questionnaires (FertiQoL, FPI) have demonstrated validity and responsiveness; however, these are inconsistently applied in practice. Knowledge gaps remain regarding routine implementation, timing, and frequency of assessment, and integration with clinical staging or fertility indices (e.g., EFI). Global frameworks such as the WERF EPHect platform facilitate standardized clinical and surgical data capture, though their use is primarily in research rather than routine care. Conclusions: We recommend combining a disease-specific PROM (EHP-30/EHP-5) with a generic instrument (SF-36 or EQ-5D) and adding FertiQoL when fertility is relevant. PROMs should be collected longitudinally (baseline, post-intervention, follow-up) and interpreted alongside clinical context, including pain phenotype, surgical staging (#Enzian/rASRM), and fertility goals. Embedding PROMs into multidisciplinary pathways enables shared decision-making, individualized treatment planning, and improved comparability of patient-centered outcomes. Full article

Background/Objectives: The relationship between body mass index (BMI) and endometriosis symptoms or lesion types remains unclear. This study investigates the association between BMI and symptom severity as well as the anatomical distribution of endometriosis using the #ENZIAN classification. Methods: A retrospective analysis was conducted on 219 patients with histologically confirmed endometriosis who underwent laparoscopic surgery at a tertiary endometriosis center in 2021. Preoperative symptom data were collected using standardized questionnaires. Patients were grouped by BMI categories based on WHO criteria. Endometriosis was classified intraoperatively using the #ENZIAN system. Statistical analyses included chi-square tests and one-way ANOVA. Results: Patients with low/normal BMI (<25 kg/m², n = 150) reported significantly higher intensity of chronic pelvic pain (CPP) compared to those with overweight/obesity (≥25 kg/m², n = 69; p = 0.0026). When stratified into four BMI groups, dyspareunia was significantly less frequent in obese patients (p = 0.0306), and high-intensity CPP was less common in both underweight and obese categories compared to normal-weight patients (p = 0.0069). Infertility rates increased significantly with higher BMI (p = 0.00001). No significant differences in the distribution of endometriosis lesions across #ENZIAN compartments were observed in relation to BMI. Conclusions: Our findings indicate that BMI does not significantly influence the anatomical distribution of endometriosis lesions as defined by the #ENZIAN classification, but it does correlate with some symptom intensity and infertility. These results suggest that while BMI may not predict disease localization, it plays a role in shaping the clinical phenotype of endometriosis. Full article

Background/Objectives: Endometriosis can present as ovarian endometriosis in 15–25% of the cases. While chronic pelvic pain and dysmenorrhea dominate its clinical presentation, acute complications, such as spontaneous OMA rupture, are rare (<3%), often mimicking acute abdominal pain and necessitating emergency surgery. Diagnostic delays persist due to the condition’s rarity and overlapping symptoms with ovarian torsion or appendicitis. This study investigates the clinical features of ruptured OMAs to enhance preoperative suspicion and optimize management. Methods: From February 2011 to August 2023, 14 patients with spontaneous rupture of histologically confirmed endometriomas underwent emergency laparoscopy for acute abdominal pain in the University Hospital of Bern, Switzerland. The clinical data of these patients were analyzed to find common patterns of spontaneous endometrioma ruptures. We also conducted a literature search in PubMed, Scopus, ScienceDirect, Cochrane, and Embase databases from inception to December 2023 in order to identify other possible confounding factors. The search was based on the keywords “ruptured endometrioma”. All English full-text prospective and retrospective observational and interventional studies with at least five patients that described the clinical features and findings of women diagnosed with ruptured endometrioma and treated surgically were included. Results: The median age at operation was 37.4 (23–49) years old, and all cases presented with acute abdominal pain, with/without peritonitis. Only 3/14 patients presented with fever, while the most common laboratory finding was an elevated CRP level of 45.6 mg/L (3–100 mg/L), while leukocytosis was less pronounced, with a median of 12.2 G/L (6.04–21.4 G/L). Notably, 64.3% (9 out of 14) of the patients reported experiencing dysmenorrhea, while for the remaining 5 individuals, the presence or absence of dysmenorrhea could not be obtained. Interestingly, only one patient had undergone hormonal treatment, with a combined oral contraceptive (COC) of Ethinylestradiol (0.02 mg) and Desogestrel (0.15 mg), while the other patients either lacked awareness of their endometriosis or expressed reluctance towards hormonal downregulation therapy. The median endometrioma size was 7 cm (3.5–18 cm), and 78.57% of the cases (11 out of 14 patients) had only ovarian endometriosis, while only 3 patients had involvement of compartment A, B, or C according to the # ENZIAN classification. Conclusions: Though rare, spontaneous OMA rupture should be considered in acute abdomen cases, especially with cysts > 5 cm. Hormonal therapy may reduce rupture risk, but more research is needed to confirm this and refine diagnostic strategies. Full article

Endometriosis, a prevalent gynecological condition affecting 10–15% of reproductive-age women, involves the growth of endometrial-like tissue outside the uterine cavity. This chronic inflammatory disease can significantly impact fertility by disrupting ovulation, tubal transport, and implantation. Clinical manifestations vary widely, ranging from asymptomatic cases to severe pelvic pain, dysmenorrhea, and dyspareunia. Accurate diagnosis remains challenging, often requiring a combination of patient history, clinical examination, and imaging studies. This paper will discuss the clinical approach to endometriosis during a first-line gynecological appointment, focusing on patient history, including detailed assessment of menstrual, pelvic, and bowel symptoms, and clinical examination; thorough gynecological examination, including abdominal and pelvic palpation, speculum examination, and bimanual examination; imaging evaluation (particularly of the role of ultrasound in identifying and characterizing endometriotic lesions, including the use of the #ENZIAN classification for deep infiltrating endometriosis and evaluation of fertility impact); and discussion of the Endometriosis Fertility Index (EFI) as a tool for assessing fertility potential. This comprehensive approach aims to guide clinicians in identifying and managing endometriosis effectively, improving patient outcomes and optimizing fertility management strategies. Methods: A literature search for suitable articles published from January 1974 to 2024 in the English language was performed using PubMed. Results: Endometriosis is associated with infertility rates ranging from 20% to 68%, with mechanisms including pelvic adhesions, chronic inflammation, and immune dysregulation. The revised American Society for Reproductive Medicine (rASRM) classification and #ENZIAN classification were identified as essential tools for staging and characterizing the disease. Transvaginal ultrasound (TVS) demonstrated high diagnostic accuracy for deep infiltrating endometriosis, with a sensitivity of up to 96% and specificity of 99%. EFI emerged as a valuable predictor of natural conception post-surgery. Additionally, the review underscores the frequent co-occurrence of adenomyosis in women with endometriosis, which may further compromise fertility. Despite advancements in imaging techniques and classification systems, the variability in symptom presentation and disease progression continues to challenge early diagnosis and effective management. Conclusions: Endometriosis is a prevalent gynecological condition affecting women of reproductive age and is associated with infertility. This paper describes the diagnostic approach to endometriosis during a first-line gynecological appointment, focusing on clinical history, physical examination, and the role of imaging, particularly ultrasound, in identifying and characterizing endometriosis lesions. The adoption of standardized classification systems such as #ENZIAN and EFI enhances disease staging and fertility prognosis, allowing for tailored treatment strategies. Despite improvements in non-invasive diagnostic methods, challenges persist in correlating symptom severity with disease extent, necessitating continued research into biomarkers and novel imaging techniques. Additionally, the frequent coexistence of adenomyosis further complicates fertility outcomes, underscoring the need for comprehensive management strategies. Further research is needed to enhance early detection strategies and optimize fertility preservation techniques for affected women. Full article

Objectives: To assess the concordance of the preoperative application of the #ENZIAN classification (#ENZIANi) with the postoperative result (#ENZIANs) using surgical findings as the reference standard. Methods: This retrospective study included 282 consecutive patients with deep endometriosis undergoing surgical treatment. Preoperative assessment with transvaginal sonography and magnetic resonance imaging was compared with postoperative assessment. Concordance and diagnostic test evaluation were calculated. Results: The highest concordance was observed in the F (abdominal wall endometriosis) with k Cohen of 0.837, following the values for pelvic locations, with 0.795 for T left, 0.791 for T right, 0.776 for F (adenomyosis), 0.766 for C (rectum), and 0.75 and 0.72 for O right k and O left, respectively. The highest sensitivity was demonstrated for the P compartment *(98%), T compartment (both sides 97%), and A, B, C (94–96%), corresponding with deep endometriosis. Conclusions: Preoperative assessment using TVS/TAS + MRI with the ENZIANi score correlates well with the ENZIANs postoperative score and demonstrates good concordance in the detection and localization of deep endometriosis, thereby minimizing false negative results and ensuring accurate preoperative staging. The ENZIAN classification is well-suited to surgeon needs and benefits from continuous development. Future improvements, such as adding the expanded C module, may be considered in the next edition. Full article

Background and Objectives: The aim of this study was to find the factors associated with the severe impairment of QoSL and the factors associated with a better score in QoSL, as well as the evaluation of pain symptoms and QoSL after the complete and incomplete excision of rectovaginal nodules. Materials and methods: The present prospective study was conducted in a single tertiary center for endometriosis where 116 patients underwent laparoscopic surgery for deep endometriosis during a 3-year period. The goal of the intervention was to excise all endometriotic implants while conserving the rectum. Intraoperative findings were recorded after the intervention, and the patients were classified according to the ENZIAN classification and rASRM scores. QoSL was assessed using the EHP-30 Module C (QoSL Score). Results: When comparing the mean scores before and 2 years after the surgery, a highly significant improvement was found for QoSL and dysmenorrhea (p < 0.0001). The complete excision of rectovaginal nodules led to a significantly better QoSL and lower dyspareunia (p < 0.0001) than incomplete resection (p < 0.02). Conclusions: This prospective study proves that the complete laparoscopic excision of all endometriotic implants improved the QoSL and decreased the pain score of dyspareunia. Incomplete rectovaginal nodule excision was correlated with a poorer QoSL and a lower improvement of dysmenorrhea, dyspareunia, and chronic pelvic pain scores than complete excision. Full article

Head and neck squamous cell carcinoma (HNSCC) still represents the world’s sixth most common tumor entity, with increasing incidence. The reachability of light makes HNSCC suitable for light-based therapies such as Photochemical Internalization (PCI). The drug Bleomycin is cytotoxic and used as an anti-tumor medication. Since Bleomycin is endocytosed as a relatively large molecule, part of it is degraded in lysosomes before reaching its intracellular target. The goal of our study was to improve the intracellular availability of Bleomycin with PCI. We investigate the intracellular delivery of Bleomycin after PCI with the photosensitizer Fimaporfin. A systematic variation of Bleomycin and Fimaporfin concentrations and light irradiation led to the pronounced cell death of HNSCC cells. After optimization, the same level of tumor cell death of 75% was reached with a 20-fold lower Bleomycin concentration. This would allow treatment of HNSCC with high local tumor cell death and reduce the side effects of Bleomycin, e.g., lung fibrosis, at the same time. This demonstrates the increased efficacy of the anti-tumor medication Bleomycin in combination with PCI. Full article

Several current guidelines recommend imaging in the diagnostic work-up of deep infiltrating endometriosis (DIE). The purpose of this retrospective diagnostic test study was to evaluate the diagnostic accuracy of MRI compared to laparoscopy for the identification of pelvic DIE, considering lesion morphology using MRI. In all, 160 consecutive patients were included who received pelvic MRI for evaluation of endometriosis between October 2018 and December 2020 and underwent subsequent laparoscopy within 12 months of the MRI examination. MRI findings were categorized for suspected DIE using the Enzian classification and were additionally graded using a newly suggested deep infiltrating endometriosis morphology score (DEMS). Endometriosis was diagnosed in 108 patients (all types, i.e., purely superficial and DIE), of which 88 cases were diagnosed with DIE and 20 with solely superficial peritoneal endometriosis (i.e., not deep infiltrating endometriosis/DIE). The overall positive and negative predictive values of MRI for the diagnosis of DIE, including lesions with assumed low and medium certainty of DIE on MRI (DEMS 1–3), were 84.3% (95% CI: 75.3–90.4) and 67.8% (95% CI: 60.6–74.2), respectively, and 100.0% and 59.0% (95% CI: 54.6–63.3) when strict MRI diagnostic criteria were applied (DEMS 3). Overall sensitivity of MRI was 67.0% (95% CI: 56.2–76.7), specificity was 84.7% (95% CI: 74.3–92.1), accuracy was 75.0% (95% CI: 67.6–81.5), positive likelihood ratio (LR+) was 4.39 (95% CI: 2.50–7.71), negative likelihood ratio (LR-) was 0.39 (95% CI: 0.28–0.53), and Cohen’s kappa was 0.51 (95% CI: 0.38–0.64). When strict reporting criteria are applied, MRI can serve as a method to confirm clinically suspected DIE. Full article

Deep infiltrating endometriosis (DIE) is characterized by the presence of endometrial tissue outside the uterine cavity that infiltrates at least 5-mm deep below the peritoneal layer. Imagining examinations are the first-choice methods to detect DIE. The aim of this study is to assess whether rectal water contrast transvaginal sonography (RWC-TVS) can be a useful tool for the estimation of the size of deep bowel endometriotic nodules. This retrospective study includes 31 patients subjected to RWC-TVS who underwent surgery due to deep bowel endometriosis between January 2021 and December 2022. Nodule dimensions measured via ultrasound were compared to those of histopathological samples taken after surgery. In total, 52% of patients had endometriosis limited only to the intestines, 19% had endometriotic nodules located at uterosacral ligaments and posterior vaginal fornix, 6% at the anterior compartment, and 13% at a different location. Additionally, 6% of patients had nodules at more than two locations. In all but one case, the intestinal nodules could be seen on RWC-TVS images. The largest nodule dimension measured via RWC-TVS and the size of the equivalent histopathological sample correlated (R = 0.406, p = 0.03). Thus, RWC-TVS allows for the detection of DIE and moderate estimation of the nodule sizes and should be practiced during a diagnostic process. Full article

Endometriosis is a common gynaecological disease, causing symptoms such as pelvic pain and infertility. Accurate diagnosis and assessment are often challenging. Transvaginal ultrasound (TVS), along with magnetic resonance imaging (MRI), are the most common imaging modalities. In this narrative review, we present the evidence behind the role of TVS in the diagnosis and assessment of endometriosis. We recognize three forms of endometriosis: Ovarian endometriomas (OMAs) can be adequately assessed by transvaginal ultrasound. Superficial peritoneal endometriosis (SUP) is challenging to diagnose by either imaging modality. TVS, in the hands of appropriately trained clinicians, appears to be non-inferior to MRI in the diagnosis and assessment of deep infiltrating endometriosis (DIE). The IDEA consensus standardized the terminology and offered a structured approach in the assessment of endometriosis by ultrasound. TVS can be used in the non-invasive staging of endometriosis using the available classification systems (rASRM, #ENZIAN). Given its satisfactory overall diagnostic accuracy, wide availability, and low cost, it should be considered as the first-line imaging modality in the diagnosis and assessment of endometriosis. Modifications to the original ultrasound technique can be employed on a case-by-case basis. Improved training and future advances in ultrasound technology are likely to further increase its diagnostic performance. Full article