ENDORECT: a preoperative score to accurately predict rectosigmoid involvement in patients with endometriosis

Bowel Endometriosis: Systematic Approach to Diagnosis with US and MRI

Endometriosis involving the bowel is a severe form of the disease, and the bowel is the most common site of extragenital endometriosis. Surface lesions of the bowel are considered peritoneal disease. Bowel endometriosis (BE) is defined as endometriotic tissue infiltrating the muscularis propria layer of the bowel wall. BE is estimated to affect up to 37% of patients with known deep endometriosis, highlighting its coexistence with genital endometriosis. The rectosigmoid colon is the most common segment of the bowel involved, followed by the distal small bowel. US and MRI are the most common imaging modalities used to detect BE. Depending on which bowel segment is imaged, endometriosis protocols for transvaginal US after bowel preparation with a transabdominal component and MRI and MR enterography are most commonly used. The authors provide a systematic approach to the diagnosis of BE using these imaging modalities. Imaging protocols and techniques for optimization of visualization of the bowel are discussed, the normal bowel wall anatomy with both imaging modalities is described, and the varying degrees of bowel wall involvement in endometriosis are illustrated. The imaging features of infiltration of endometriosis in the bowel muscularis propria are described in detail, along with key imaging findings to be conveyed to surgical colleagues to optimize surgical treatment and decrease complications, thereby improving overall patient outcomes. ©RSNA, 2025 Supplemental material is available for this article.

Feasibility of Predicting Surgical Duration in Endometriosis Using Numerical Multi-Scoring System of Endometriosis (NMS-E)

BACKGROUND

Endometriosis is a multifaceted gynecological condition that poses diagnostic challenges and affects a significant number of women worldwide, leading to pain, infertility, and a reduction in patient quality of life (QoL). Traditional diagnostic methods, such as the revised American Society for Reproductive Medicine (r-ASRM) classification, have limitations, particularly in preoperative settings. The Numerical Multi-Scoring System of Endometriosis (NMS-E) has been proposed to address these shortcomings by providing a comprehensive preoperative diagnostic tool that integrates findings from pelvic examinations and transvaginal ultrasonography.

METHODS

This retrospective study aims to validate the effectiveness of the NMS-E in predicting surgical outcomes and correlating with the severity of endometriosis. Data from 111 patients at Nippon Medical School Hospital were analyzed to determine the correlation between NMS-E scores, including E-score-a severity indicator-traditional scoring systems, surgical duration, blood loss, and clinical symptoms. This study also examined the need to refine parameters for deep endometriosis within the NMS-E to enhance its predictive accuracy for disease severity.

RESULTS

The mean age of the patient cohort was 35.1 years, with the majority experiencing symptoms such as dysmenorrhea, dyspareunia, and chronic pelvic pain. A statistically significant positive correlation was observed between the NMS-E's E-score and the severity of endometriosis, particularly in predicting surgical duration (Spearman correlation coefficient: 0.724, p < 0.01) and blood loss (coefficient: 0.400, p < 0.01). The NMS-E E-score also correlated strongly with the r-ASRM scores (coefficient: 0.758, p < 0.01), exhibiting a slightly more excellent predictive value for surgical duration than the r-ASRM scores alone. Refinements in the methodology for scoring endometriotic nodules in uterine conditions improved the predictive accuracy for surgical duration (coefficient: 0.752, p < 0.01).

CONCLUSIONS

Our findings suggest that the NMS-E represents a valuable preoperative diagnostic tool for endometriosis, effectively correlating with the disease's severity and surgical outcomes. Incorporating the NMS-E into clinical practice could significantly enhance the management of endometriosis by addressing current diagnostic limitations and guiding surgical planning.

Do women with suspected endometriosis benefit from pelvic examination to improve diagnostic and management strategy?

OBJECTIVE

To analyze the literature and expose best evidence available regarding the benefit of pelvic examination for women with suspected endometriosis METHODS: the AGREE II and GRADE systems for grading scientific evidence.

RESULTS

Endometriosis is characterized by the heterogeneity in its clinical presentation with many different symptoms reported by patients. In the literature, questioning for each symptom has a high sensitivity, reaching 76-98 %, but lacks specificity (20 - 58 %). The symptom-based approach is limited by its low specificity, the absence of external validation for most of the models developed and the inability to characterize the extent of the disease, which could have major implications in the decision - making process. The latest systematic review and meta-analysis included a total of 30 studies with 4,565 participants, compared the diagnostic performance of several modalities for endometriosis. Physical examination had a pooled sensitivity of 71 % and a specificity of 69 %, with an average diagnostic accuracy of 0.76. Overall, the value of pelvic examination is conferred by its high positive likehood ratio and specificity. Besides its diagnostic value, pelvic examination improves patients' management by allowing the identification of a possible myofascial syndrome as a differential diagnosis. It also increases the quality of the preoperative workup and influences the quality of surgical excision and decreases the time to diagnosis.

CONCLUSION

Despite the lack of studies in the primary care context, pelvic examination (vaginal speculum and digital vaginal examination) increases the diagnostic value for suspected endometriosis in association with questioning for symptoms.

Endometriosis Predictive Models Based on Self-Assessment Questionnaire, Evidence from Clinical Examination or Imaging Findings: A Narrative Review

OBJECTIVE

The aim of this narrative review is to evaluate existing questionnaires on predictive models for endometriosis. These symptom-based models have the potential to serve as screening tools for adult women to detect endometriosis.

DATA SOURCES

A comprehensive search of PubMed and Embase databases was conducted to identify studies on endometriosis screening.

SELECTION OF STUDIES

The search targeted predictive models for endometriosis localisation, bowel involvement, need for bowel surgery and fertility. Due to the heterogeneity identified, a systematic review was not possible. A total of 23 studies were identified.

DATA EXTRACTION AND SYNTHESIS

Among these studies, twelve included measures for general endometriosis, two targeted specific sites, four focused on deep infiltrating endometriosis (DIE), and three addressed the need for endometriosis-related bowel surgery. Many measures combined clinical, imaging and laboratory tests with patient questionnaires. Validation of these models as screening tools was lacking in all studies, as the focus was on diagnosis rather than screening.

CONCLUSION

This review did not identify any fully validated, symptom-based questionnaires for endometriosis screening in adult women. Substantial validation work remains to establish the efficacy of such tools.

[Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]

OBJECTIVE

To provide guidelines for the pelvic clinical exam in gynecology and obstetrics.

MATERIAL AND METHODS

A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature.

CONCLUSIONS

The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.

Clinical use of artificial intelligence in endometriosis: a scoping review

Endometriosis is a chronic, debilitating, gynecologic condition with a non-specific clinical presentation. Globally, patients can experience diagnostic delays of ~6 to 12 years, which significantly hinders adequate management and places a significant financial burden on patients and the healthcare system. Through artificial intelligence (AI), it is possible to create models that can extract data patterns to act as inputs for developing interventions with predictive and diagnostic accuracies that are superior to conventional methods and current tools used in standards of care. This literature review explored the use of AI methods to address different clinical problems in endometriosis. Approximately 1309 unique records were found across four databases; among those, 36 studies met the inclusion criteria. Studies were eligible if they involved an AI approach or model to explore endometriosis pathology, diagnostics, prediction, or management and if they reported evaluation metrics (sensitivity and specificity) after validating their models. Only articles accessible in English were included in this review. Logistic regression was the most popular machine learning method, followed by decision tree algorithms, random forest, and support vector machines. Approximately 44.4% (n = 16) of the studies analyzed the predictive capabilities of AI approaches in patients with endometriosis, while 47.2% (n = 17) explored diagnostic capabilities, and 8.33% (n = 3) used AI to improve disease understanding. Models were built using different data types, including biomarkers, clinical variables, metabolite spectra, genetic variables, imaging data, mixed methods, and lesion characteristics. Regardless of the AI-based endometriosis application (either diagnostic or predictive), pooled sensitivities ranged from 81.7 to 96.7%, and pooled specificities ranged between 70.7 and 91.6%. Overall, AI models displayed good diagnostic and predictive capacity in detecting endometriosis using simple classification scenarios (i.e., differentiating between cases and controls), showing promising directions for AI in assessing endometriosis in the near future. This timely review highlighted an emerging area of interest in endometriosis and AI. It also provided recommendations for future research in this field to improve the reproducibility of results and comparability between models, and further test the capacity of these models to enhance diagnosis, prediction, and management in endometriosis patients.

A new validated screening method for endometriosis diagnosis based on patient questionnaires

BACKGROUND

The time between symptoms onset and endometriosis diagnosis is usually long. The negative impacts of delayed endometriosis diagnosis can affect patients and health outcomes.

METHODS

We conducted a case-control study using clinical symptoms and epidemiological data extracted from a prospective pre-operative patient questionnaire compared between patients with histologically proven endometriosis and patients with no endometriosis at surgical exploration from 2005 to 2018, in a French referral center. We used the beta coefficients of the significant variables introduced in a multiple regression model to devise a score (score 1), evaluated by the area under the curve (or C-index), with three levels, defined by a score between 1 and ≥ 25: (i) highly specific, identifying correctly the patients without the disease; (ii) highly sensitive, identifying the patients with the disease; and (iii) a level maximizing sensitivity and specificity for the best classification of the whole population. To minimize patient self-evaluation of pain, we devised a second score (score 2) with the same method and levels and scores definition, excluding visual analog scale pain scores, except for dysmenorrhea. These scores were validated on an internal and external population.

FINDINGS

Score 1 had a C-index of 0.81 (95% CI [0.79-0.83]). Results for the three score 1 levels were: ≥ 25: specificity of 91% (95% CI [89-93]); < 11: sensitivity of 91% (95% CI [89-93]); ≥ 18: specificity of 75% (95% CI [72-78]) and sensitivity of 73% (95% CI [70-76]). Score 2 had a C-index of 0.75 (95% CI [73-77]). The three levels of score 2 were: ≥ 24: specificity of 82% (95% CI [80-85]); < 7: sensitivity of 92% (95% CI [90-94]); ≥ 17: specificity of 62% (95% CI [58-65]) and sensitivity of 78% (95% CI [75-81]). The two scores were internally and externally validated.

INTERPRETATION

A score based only on a patient questionnaire could allow identification of a population at high risk of endometriosis. This strategy might help referral to specialized radiologists for a non-surgical endometriosis scan.

FUNDING

None.

Endometriosis Classification, Staging and Reporting Systems: A Review on the Road to a Universally Accepted Endometriosis Classification

OBJECTIVE

In the field of endometriosis, several classification, staging and reporting systems have been developed. Which endometriosis classification, staging and reporting systems have been published and validated for use in clinical practice?

DATA SOURCES

A systematic PUBMED literature search was performed. Data were extracted and summarized.

METHODS OF STUDY SELECTION

na TABULATION, INTEGRATION AND RESULTS: Twenty-two endometriosis classification, staging and reporting systems have been published between 1973 and 2021, each developed for specific, and different, purposes. There still is no international agreement on how to describe the disease. Studies evaluating the different systems are summarized showing a discrepancy between the intended and the evaluated purpose, and a general lack of validation data confirming a correlation with pain symptoms or quality of life for any of the current systems. A few studies confirm the value of the ENZIAN system for surgical description of deep endometriosis. With regards to infertility, the endometriosis fertility index has been confirmed valid for its intended purpose.

CONCLUSION

Of the 22 endometriosis classification, staging and reporting systems identified in this historical overview, only a few have been evaluated for the purpose for which they were developed. The literature search was limited to PUBMED. Unpublished classification, staging or reporting systems, or those published in books were not considered. It can be concluded that there is no international agreement on how to describe endometriosis or how to classify it, and that most classification/staging systems show no or very little correlation with patient outcomes. This overview of existing systems is a first step in working towards a universally accepted endometriosis classification.

Vermeulen N, Abrao MS, Einarsson JI, Horne AW, Johnson NP, Lee TTM, Missmer S, Petrozza J, Tomassetti C, Zondervan KT, Grimbizis G, De Wilde RL. Endometriosis classification, staging and reporting systems: a review on the road to a universally accepted endometriosis classification. Hum Reprod Open 2021;2021:hoab025. [PMID: 34693032 PMCID: PMC8530712 DOI: 10.1093/hropen/hoab025]

STUDY QUESTION

Which endometriosis classification, staging and reporting systems have been published and validated for use in clinical practice?

SUMMARY ANSWER

Of the 22 endometriosis classification, staging and reporting systems identified in this historical overview, only a few have been evaluated, in 46 studies, for the purpose for which they were developed.

WHAT IS KNOWN ALREADY

In the field of endometriosis, several classification, staging and reporting systems have been developed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A systematic PUBMED literature search was performed. Data were extracted and summarized.

MAIN RESULTS AND THE ROLE OF CHANCE

Twenty-two endometriosis classification, staging and reporting systems have been published between 1973 and 2021, each developed for specific, and different, purposes. There still is no international agreement on how to describe the disease. Studies evaluating the different systems are summarized showing a discrepancy between the intended and the evaluated purpose, and a general lack of validation data confirming a correlation with pain symptoms or quality of life for any of the current systems. A few studies confirm the value of the ENZIAN system for surgical description of deep endometriosis. With regards to infertility, the endometriosis fertility index has been confirmed valid for its intended purpose.

LARGE SCALE DATA

NA.

LIMITATIONS, REASONS FOR CAUTION

The literature search was limited to PUBMED. Unpublished classification, staging or reporting systems, or those published in books were not considered.

WIDER IMPLICATIONS OF THE FINDINGS

It can be concluded that there is no international agreement on how to describe endometriosis or how to classify it, and that most classification/staging systems show no or very little correlation with patient outcomes. This overview of existing systems is a first step in working toward a universally accepted endometriosis classification.

STUDY FUNDING/COMPETING INTEREST(S)

The meetings and activities of the working group were funded by the American Association of Gynecologic Laparoscopists, European Society for Gynecological Endoscopy, European Society of Human Reproduction and Embryology and World Endometriosis Society. A.W.H. reports grant funding from the MRC, NIHR, CSO, Wellbeing of Women, Roche Diagnostics, Astra Zeneca, Ferring, Charles Wolfson Charitable Trust, Standard Life, Consultancy fees from Roche Diagnostics, AbbVie, Nordic Pharma and Ferring, outside the submitted work. In addition, A.W.H. has a patent Serum biomarker for endometriosis pending. N.P.J. reports personal fees from Abbott, Guerbet, Myovant Sciences, Vifor Pharma, Roche Diagnostics, outside the submitted work; he is also President of the World Endometriosis Society and chair of the trust board. S.M. reports grants and personal fees from AbbVie, and personal fees from Roche outside the submitted work. C.T. reports grants, non-financial support and other from Merck SA, non-financial support and other from Gedeon Richter, non-financial support from Ferring Pharmaceuticals, outside the submitted work and without private revenue. K.T.Z. reports grants from Bayer Healthcare, MDNA Life Sciences, Roche Diagnostics Inc, Volition Rx, outside the submitted work; she is also a Board member (Secretary) of the World Endometriosis Society and World Endometriosis Research Foundation, Research Advisory Board member of Wellbeing of Women, UK (research charity), and Chair, Research Directions Working Group, World Endometriosis Society. The other authors had nothing to disclose.

TRIAL REGISTRATION NUMBER

NA.

Vermeulen N, Abrao MS, Einarsson JI, Horne AW, Johnson NP, Lee TTM, Missmer S, Petrozza J, Tomassetti C, Zondervan KT, Grimbizis G, De Wilde RL. Endometriosis classification, staging and reporting systems: a review on the road to a universally accepted endometriosis classification

Background

In the field of endometriosis, several classification, staging and reporting systems have been developed. However, endometriosis classification, staging and reporting systems that have been published and validated for use in clinical practice have not been systematically reviewed up to now.

Objectives

The aim of the current review is to provide a historical overview of these different systems based on an assessment of published studies.

Materials and Methods

A systematic Pubmed literature search was performed. Data were extracted and summarised.

Results

Twenty-two endometriosis classification, staging and reporting systems have been published between 1973 and 2021, each developed for specific and different purposes. There is still no international agreement on how to describe the disease. Studies evaluating different systems are summarised showing a discrepancy between the intended and the evaluated purpose, and a general lack of validation data confirming a correlation with pain symptoms or quality of life for any of the current systems. A few studies confirm the value of the Enzian system for surgical description of deep endometriosis. With regards to infertility, the endometriosis fertility index has been confirmed valid for its intended purpose.

Conclusions

Of the 22 endometriosis classification, staging and reporting systems identified in this historical overview, only a few have been evaluated, in 46 studies, for the purpose for which they were developed. It can be concluded that there is no international agreement on how to describe endometriosis or how to classify it, and that most classification/staging systems show no or very little correlation with patient outcomes.

What is new?

This overview of existing systems is a first step in working towards a universally accepted endometriosis classification.

Imaging of gastrointestinal endometriosis: what the radiologist should know

Deep invasive gastrointestinal endometriosis (DIGIE) is a frequent and severe presentation of endometriosis. Although most cases invade the rectosigmoid colon, DIGIE can involve any portion of the gastrointestinal tract from the stomach to the rectum, and is commonly multifocal and multicentric. Although histopathologic confirmation with surgery remains the gold standard for diagnosis, ultrasound (US) and magnetic resonance imaging (MRI) are the key non-invasive imaging modalities for initial assessment. US may be preferred as a screening study because of its easy availability and low-cost. Pelvic MRI and magnetic resonance enterography (MRE) provide substantial advantages for disease mapping in the pre-operative period, particularly in extensive bowel endometriosis. Although medical management of DIGIE with hormonal therapy can help control symptoms, disease course can be relentless and require surgical intervention. Surgical options depend on, the location; length; depth; circumference; multicentric or multifocal disease. With procedures including simple excision, fulguration of superficial lesions, shaving, disc excision, and segmental resection. A successful treatment outcome is largely dependent on good communication between the treating surgeon and the radiologist, who can provide vital information for effective surgical planning by reporting the key elements that we elaborate upon in this paper.

Recommendations for the surgical treatment of endometriosis Part 2: deep endometriosis †‡¶

STUDY QUESTION

How should surgery for endometriosis be performed?

SUMMARY ANSWER

This document provides recommendations covering technical aspects of different methods of surgery for deep endometriosis in women of reproductive age.

WHAT IS KNOWN ALREADY

Endometriosis is highly prevalent and often associated with severe symptoms. Yet compared to equally prevalent conditions it is poorly understood and a challenge to manage. Previously published guidelines have provided recommendations for (surgical) treatment of deep endometriosis, based on the best available evidence, but without technical information and details on how to best perform such treatment in order to be effective and safe.

STUDY DESIGN SIZE DURATION

A working group of the European Society for Gynaecological Endoscopy (ESGE), European Society of Human Reproduction and Embryology (ESHRE) and the World Endometriosis Society (WES) collaborated on writing recommendations on the practical aspects of surgery for treatment of deep endometriosis.

PARTICIPANTS MATERIALS SETTING METHODS

This document focused on surgery for deep endometriosis, and is complementary to a previous document in this series focusing on endometrioma surgery.

MAIN RESULTS AND THE ROLE OF CHANCE

The document presents general recommendations for surgery for deep endometriosis, starting from preoperative assessments and first steps of surgery. Different approaches for surgical treatment are discussed and are respective of location and extent of disease; uterosacral ligaments and rectovaginal septum with or without involvement of the rectum, urinary tract or extrapelvic endometriosis. In addition, recommendations are provided on the treatment of frozen pelvis and on hysterectomy as a treatment for deep endometriosis.

LIMITATIONS REASONS FOR CAUTION

Owing to the limited evidence available, recommendations are mostly based on clinical expertise. Where available, references of relevant studies were added.

WIDER IMPLICATIONS OF THE FINDINGS

These recommendations complement previous guidelines on management of endometriosis and the recommendations for surgical treatment of ovarian endometrioma.

STUDY FUNDING - COMPETING INTERESTS

The meetings of the working group were funded by ESGE, ESHRE and WES.Dr. Roman reports personal fees from ETHICON, PLASMASURGICAL, OLYMPUS, and NORDIC PHARMA, outside the submitted work; Dr. Becker reports grants from Bayer AG, Volition Rx, MDNA Life Sciences, and Roche Diagnostics Inc, and other relationships or activities from AbbVie Inc, and Myriad Inc, during the conduct of the study; Dr. Tomassetti reports non-financial support from ESHRE, during the conduct of the study; non-financial support and other from Lumenis, Gedeon-Richter, Ferring Pharmaceuticals, and Merck SA, outside the submitted work. The other authors had nothing to disclose.

Working group of ESGE, ESHRE, and WES, Keckstein J, Becker CM, Canis M, Feki A, Grimbizis GF, Hummelshoj L, Nisolle M, Roman H, Saridogan E, Tanos V, Tomassetti C, Ulrich UA, Vermeulen N, De Wilde RL. Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis

STUDY QUESTION

How should surgery for endometriosis be performed?

SUMMARY ANSWER

This document provides recommendations covering technical aspects of different methods of surgery for deep endometriosis in women of reproductive age.

WHAT IS KNOWN ALREADY

Endometriosis is highly prevalent and often associated with severe symptoms. Yet compared to equally prevalent conditions, it is poorly understood and a challenge to manage. Previously published guidelines have provided recommendations for (surgical) treatment of deep endometriosis, based on the best available evidence, but without technical information and details on how to best perform such treatment in order to be effective and safe.

STUDY DESIGN SIZE DURATION

A working group of the European Society for Gynaecological Endoscopy (ESGE), ESHRE and the World Endometriosis Society (WES) collaborated on writing recommendations on the practical aspects of surgery for treatment of deep endometriosis.

PARTICIPANTS/MATERIALS SETTING METHODS

This document focused on surgery for deep endometriosis and is complementary to a previous document in this series focusing on endometrioma surgery.

MAIN RESULTS AND THE ROLE OF CHANCE

The document presents general recommendations for surgery for deep endometriosis, starting from preoperative assessments and first steps of surgery. Different approaches for surgical treatment are discussed and are respective of location and extent of disease; uterosacral ligaments and rectovaginal septum with or without involvement of the rectum, urinary tract or extrapelvic endometriosis. In addition, recommendations are provided on the treatment of frozen pelvis and on hysterectomy as a treatment for deep endometriosis.

LIMITATIONS REASONS FOR CAUTION

Owing to the limited evidence available, recommendations are mostly based on clinical expertise. Where available, references of relevant studies were added.

WIDER IMPLICATIONS OF THE FINDINGS

These recommendations complement previous guidelines on management of endometriosis and the recommendations for surgical treatment of ovarian endometrioma.

STUDY FUNDING/COMPETING INTERESTS

The meetings of the working group were funded by ESGE, ESHRE and WES. Dr Roman reports personal fees from ETHICON, PLASMASURGICAL, OLYMPUS and NORDIC PHARMA, outside the submitted work; Dr Becker reports grants from Bayer AG, Volition Rx, MDNA Life Sciences and Roche Diagnostics Inc. and other relationships or activities from AbbVie Inc., and Myriad Inc, during the conduct of the study; Dr Tomassetti reports non-financial support from ESHRE, during the conduct of the study; and non-financial support and other were from Lumenis, Gedeon-Richter, Ferring Pharmaceuticals and Merck SA, outside the submitted work. The other authors had nothing to disclose.

TRIAL REGISTRATION NUMBER

na.