{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,11]],"date-time":"2026-06-11T11:29:20Z","timestamp":1781177360522,"version":"3.54.1"},"reference-count":30,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,7,25]],"date-time":"2025-07-25T00:00:00Z","timestamp":1753401600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:sec><jats:title>Objective<\/jats:title><jats:p>Endometriosis is a multifactorial disease that affects mainly women of reproductive age. It is unclear whether each form of pelvic endometriosis is an independent entity and whether a spatial relationship between all three endometriosis forms exists. We aimed with this research to examine the distribution of deep endometriosis in patients with ovarian endometriomas. We also aimed to assess the influence of unilateral and bilateral ovarian endometriomas on the distribution of deep endometriotic nodules.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>This is a retrospective single-center cohort study that included all patients with histologically-proven ovarian endometriomas. The #Enzian classification was used to classify endometriosis. The distribution of deep endometriosis in patients with endometriomas was assessed.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>A total of 106 out of 121 patients with ovarian endometriomas had coexisting deep endometriosis (87.6%). Bilateral endometriomas were more common than unilateral ones. There was a statistically significant correlation between ipsilateral ovarian endometriomas and same-sided deep endometriosis of the pelvic compartment B according to the #Enzian classification. Patients with bilateral ovarian endometriomas had deep endometriosis of the left #Enzian B pelvic compartment and rectovaginal septum at a higher frequency than patients with unilateral endometriomas.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Deep Endometriosis coexists with unilateral or bilateral ovarian endometriomas in the great majority of patients. Bilateral endometriomas are associated with higher frequencies of deep endometriosis in the left #Enzian B compartment and rectovaginal septum (#Enzian A). In order to avoid incomplete surgeries and complications, patients with endometriomas should be carefully screened for deep endometriosis of the pelvis using transvaginal ultrasound or MR imaging.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fmed.2025.1626445","type":"journal-article","created":{"date-parts":[[2025,7,25]],"date-time":"2025-07-25T05:25:52Z","timestamp":1753421152000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":4,"title":["Mapping deep endometriosis in patients with ovarian endometriomas according to the #Enzian classification: a single-center retrospective analysis"],"prefix":"10.3389","volume":"12","author":[{"given":"Vimee","family":"Bindra","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antoine","family":"Naem","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"P.","family":"Swetha","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joelle","family":"Kahla","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Archana","family":"Reddy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonio Simone","family":"Lagan\u00e0","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea","family":"Etrusco","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dimitrios","family":"Andrikos","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gaetano","family":"Riemma","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vittorio","family":"Agrifoglio","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alin","family":"Constantin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rudy Leon","family":"De Wilde","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Harald","family":"Krentel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2025,7,25]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"1244","DOI":"10.1056\/NEJMra1810764","article-title":"Endometriosis","volume":"382","author":"Zondervan","year":"2020","journal-title":"N Engl J Med"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"667","DOI":"10.1007\/s00404-012-2361-z","article-title":"Endometriosis: a premenopausal disease? Age pattern in 42,079 patients with endometriosis","volume":"286","author":"Haas","year":"2012","journal-title":"Arch Gynecol Obstet"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1016\/j.bpobgyn.2018.06.001","article-title":"Risk for and consequences of endometriosis: a critical epidemiologic review","volume":"51","author":"Shafrir","year":"2018","journal-title":"Best Pract Res Clin Obstet Gynaecol"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"177","DOI":"10.1016\/j.bpobgyn.2004.01.007","article-title":"Endometriosis: epidemiology and aetiological factors","volume":"18","author":"Vigan\u00f2","year":"2004","journal-title":"Best Pract Res Clin Obstet Gynaecol"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"261","DOI":"10.1038\/nrendo.2013.255","article-title":"Endometriosis: pathogenesis and treatment","volume":"10","author":"Vercellini","year":"2014","journal-title":"Nat Rev Endocrinol"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"e125","DOI":"10.1016\/j.fertnstert.2019.08.081","article-title":"Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities","volume":"112","author":"Nisolle","year":"2019","journal-title":"Fertil Steril"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"1211","DOI":"10.1016\/j.jogc.2020.04.007","article-title":"Prevalence of deep endometriosis and rectouterine pouch obliteration in the presence of normal ovaries","volume":"42","author":"Leonardi","year":"2020","journal-title":"J Obstet Gynaecol Can"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"915","DOI":"10.1016\/j.fertnstert.2022.07.024","article-title":"Prevalence of Endometrioma and deep infiltrating endometriosis at transvaginal ultrasound examination of subfertile women undergoing assisted reproductive treatment","volume":"118","author":"Alson","year":"2022","journal-title":"Fertil Steril"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"564","DOI":"10.1016\/j.fertnstert.2012.07.1061","article-title":"Deep endometriosis: definition, diagnosis, and treatment","volume":"98","author":"Koninckx","year":"2012","journal-title":"Fertil Steril"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"924","DOI":"10.1016\/s0015-0282(16)55436-3","article-title":"Deep endometriosis: a consequence of infiltration or retraction or possibly Adenomyosis externa?","volume":"58","author":"Koninckx","year":"1992","journal-title":"Fertil Steril"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"1849","DOI":"10.1016\/j.jmig.2021.08.032","article-title":"An international terminology for endometriosis, 2021","volume":"28","author":"Tomassetti","year":"2021","journal-title":"J Minim Invasive Gynecol"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"209","DOI":"10.3760\/cma.j.issn.0366-6999.2012.02.009","article-title":"Anatomical distribution of pelvic deep infiltrating endometriosis and its relationship with pain symptoms","volume":"125","author":"Dai","year":"2012","journal-title":"Chin Med J"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"36","DOI":"10.1016\/j.ejogrb.2018.09.001","article-title":"Anatomic distribution of endometriosis: a reappraisal based on series of 1101 patients","volume":"230","author":"Audebert","year":"2018","journal-title":"Eur J Obstet Gynecol Reprod Biol"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"978","DOI":"10.1016\/s0015-0282(16)53570-5","article-title":"Deeply infiltrating pelvic endometriosis: histology and clinical significance","volume":"53","author":"Cornillie","year":"1990","journal-title":"Fertil Steril"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"329","DOI":"10.1093\/humupd\/dmv003","article-title":"Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management","volume":"21","author":"Abr\u00e3o","year":"2015","journal-title":"Hum Reprod Update"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"102536","DOI":"10.1016\/j.bpobgyn.2024.102536","article-title":"Bladder endometriosis: what do we know and what is left to find out? A narrative review","volume":"96","author":"Fleischer","year":"2024","journal-title":"Best Pract Res Clin Obstet Gynaecol"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"710","DOI":"10.1093\/humupd\/dmy027","article-title":"Ureteral endometriosis: a systematic review of epidemiology, pathogenesis, diagnosis, treatment, risk of malignant transformation and fertility","volume":"24","author":"Barra","year":"2018","journal-title":"Hum Reprod Update"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"1165","DOI":"10.1111\/aogs.14099","article-title":"The #Enzian classification: a comprehensive non-invasive and surgical description system for endometriosis","volume":"100","author":"Keckstein","year":"2021","journal-title":"Acta Obstet Gynecol Scand"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"e1001885","DOI":"10.1371\/journal.pmed.1001885","article-title":"The reporting of studies conducted using observational routinely-collected health data (Record) statement","volume":"12","author":"Benchimol","year":"2015","journal-title":"PLoS Med"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"118","DOI":"10.1002\/uog.24786","article-title":"Consensus on revised definitions of morphological uterus sonographic assessment (Musa) features of Adenomyosis: results of modified Delphi procedure","volume":"60","author":"Harmsen","year":"2022","journal-title":"Ultrasound Obstet Gynecol"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"111","DOI":"10.1186\/s12905-020-00974-y","article-title":"Lesion distribution characteristics of deep infiltrating endometriosis with ovarian Endometrioma: an observational clinical study","volume":"20","author":"Kwok","year":"2020","journal-title":"BMC Womens Health"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"168","DOI":"10.1093\/humrep\/deg513","article-title":"Association rate between deep peritoneal endometriosis and other forms of the disease: Pathogenetic implications","volume":"19","author":"Somigliana","year":"2004","journal-title":"Hum Reprod"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"1839","DOI":"10.1093\/humrep\/del079","article-title":"Deeply infiltrating endometriosis: Pathogenetic implications of the anatomical distribution","volume":"21","author":"Chapron","year":"2006","journal-title":"Hum Reprod"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"157","DOI":"10.1093\/humrep\/deg009","article-title":"Anatomical distribution of deeply infiltrating endometriosis: surgical implications and proposition for a classification","volume":"18","author":"Chapron","year":"2003","journal-title":"Hum Reprod"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"133","DOI":"10.4274\/jtgga.galenos.2018.2018.0120","article-title":"Clinical characteristics and location of lesions in patients with deep infiltrating endometriosis using the revised Enzian classification","volume":"20","author":"Morgan-Ortiz","year":"2019","journal-title":"J Turk Ger Gynecol Assoc"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"2359","DOI":"10.1093\/humrep\/dem224","article-title":"Asymmetry in distribution of diaphragmatic Endometriotic lesions: evidence in favour of the menstrual reflux theory","volume":"22","author":"Vercellini","year":"2007","journal-title":"Hum Reprod"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"6455","DOI":"10.3390\/jcm12206455","article-title":"Diaphragmatic endometriosis-a single-center retrospective analysis of the patients' demographics, symptomatology, and long-term treatment outcomes","volume":"12","author":"Naem","year":"2023","journal-title":"J Clin Med"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"419","DOI":"10.1016\/j.fertnstert.2006.06.028","article-title":"Lateral distribution of Endometriomas as a function of age","volume":"87","author":"Bazi","year":"2007","journal-title":"Fertil Steril"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"761","DOI":"10.1016\/j.athoracsur.2005.07.044","article-title":"Thoracic endometriosis: current knowledge","volume":"81","author":"Alifano","year":"2006","journal-title":"Ann Thorac Surg"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"524","DOI":"10.1016\/j.fertnstert.2022.05.030","article-title":"Molecular analysis suggests Oligoclonality and metastasis of endometriosis lesions across anatomically defined subtypes","volume":"118","author":"Praetorius","year":"2022","journal-title":"Fertil Steril"}],"container-title":["Frontiers in Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2025.1626445\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,7,25]],"date-time":"2025-07-25T05:25:53Z","timestamp":1753421153000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2025.1626445\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,7,25]]},"references-count":30,"alternative-id":["10.3389\/fmed.2025.1626445"],"URL":"https:\/\/doi.org\/10.3389\/fmed.2025.1626445","relation":{},"ISSN":["2296-858X"],"issn-type":[{"value":"2296-858X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,7,25]]},"article-number":"1626445"}}