P-317 Association between pre-operative symptoms and surgically diagnosed endometriosis using the #ENZIAN classification in a multi-center cohort

Abstract Study question Do pre-operative symptoms correlate to the localization and size of endometriosis lesions found operatively? Summary answer Dyschezia was associated with deep infiltrating endometriosis (DE) lesions in #ENZIAN compartments A, B and C, while severe dyspareunia was associated with adenomyosis (FA) What is known already Endometriosis is a common cause of pelvic pain, characterized by dysmenorrhea, dyspareunia, dysuria and dyschezia. Previous attempts to correlate these symptoms to the stages of endometriosis have been moderately successful. A possible explanation is that the ASRM classification system may be suboptimal for the operative description of lesion localization and infiltration, especially when assessing the extent and depth of DE. Additionally, previous studies have often been small, retrospective and did not use standardized pain scales for assessing symptoms. Study design, size, duration This prospective, multi-center cross-sectional study was conducted between September 2022 and January 2024 at 18 certified endometriosis centers in Austria, Germany and Switzerland. The study enrolled 838 symptomatic women with suspected endometriosis scheduled for first surgery. Clinical data collected pre-operatively using a standardized questionnaire included severity, timing and duration of specific endometriosis-associated symptoms. All women underwent surgical assessment and treatment of endometriosis using the #ENZIAN classifications by expert surgeons. Participants/materials, setting, methods Of the 838 participants, 58 had no operative signs of endometriosis, 521 were confirmed to have endometriosis and had complete pre-operative and surgical data to be included in the analyses. Pre-operative severity and timing of dysmenorrhea, dyspareunia, dysuria and dyschezia were collected via modified AGEM questionnaire. Associations between individual symptoms and their combinations with the localization of lesions were analyzed using Chi-square, univariate and multivariate logistic regression. Radar charts were designed to illustrate these associations. Main results and the role of chance Nearly all patients (n = 513, 98.5%) suffered from dysmenorrhea whereas 294 (56.4%), 208 (39.9%), 102 (19.6%) patients reported dyspareunia, dyschezia and dysuria, respectively. Median duration from onset of symptoms to the day of surgery was 12 (6.0-17.0) years. Peritoneal lesions, DE in compartment B as well as adenomyosis were most frequently associated with symptoms, while ovarian (O) and tubal (T) lesions and DE in compartments A and C less so.The larger the endometriosis lesion within a compartment, the higher the prevalence of patients reporting symptoms. Specifically, patients with P1 lesions suffered from dysmenorrhea, dysuria, dyschezia, and dyspareunia in 33.2%, 30.1%, 29.4%, and 32.2%, compared to 53.6%, 59.3%, 55.9%, and 52.2% in patients with P2 and P3 lesions. Similarly, larger B lesions were associated with a higher prevalence of symptoms, especially when located on the left. Dyspareunia rated as ≥ 8 on a visual analog scale was reported 3.5 fold more often in patients with adenomyosis only (OR 3.56 [1.38 - 9.17]) than those without, while dyschezia had a prevalence of nearly 50% in the presence of DE and was almost twice as likely in those with any form of DE (OR 1.86 [1.3 - 2.65]). Limitations, reasons for caution Lesions may be located in several or multiple #ENZIAN compartments, with a myriad of possible combinations of superficial and deep lesions, making it challenging to determine the anatomical etiology of symptoms. A larger study population is needed to form clinically relevant sub-groups based on localization of lesions. Wider implications of the findings A number of direct associations between symptoms and lesions were identified. Adenomyosis was a strong driver of pain, especially dyspareunia, making awareness of its high prevalence and symptomatology an issue of utmost importance. Nonetheless, endometriosis-related symptoms, especially when chronic, are multi-factorial and cannot be readily correlated to specific lesion sites. Trial registration number No