Unusual case of adenomyosis of the uterine body with malignant clinical course

We report an unusual case of adenomyosis with asymptomatic thoracic endometriosis. A 30-year old woman had a history of nephroblastoma, two missed abortions and one childbirth by caesarean section. The pregnancy was complicated with asymmetric fetus hipotrophy. Two years after delivery she had assessments for dysmenorrhea, dyspareunia, pelvic pain, and anemia. Gynaecological examination and pelvic endovaginal ultrasonography revealed enlarged uterus. Tumour structure was found with diameter ranging from 40 to 63 mm. The round focus with diameter 15 mm in the left lung by chest roentgenogram was revealed. The patient was diagnosed as follows: hysterography, curettage, bronchoscopy, laparoscopy. Hysterectomy without adnexes was performed and tumour of the left lung was resected. Histologic diagnosis revealed adenomyosis of uterine body and parenchymal pulmonary endometriosis. Two years after operations patient alive without sings of disease.     

A Systematic Review of Adenomyosis: It Is Time to Reassess What We Thought We Knew about the Disease

ObjectiveTo summarize and update our current knowledge regarding adenomyosis diagnosis, prevalence, and symptoms.Data SourcesSystematic review of PubMed between January 1972 and April 2020. Search strategy included: “adenomyosis [MeSH Terms] AND (endometriosis[MeSH Term OR prevalence study [MeSH Terms] OR dysmenorrhea[text word] OR prevalence[Text Word] OR young adults [Text Word] OR adolesce* [Text Word] OR symptoms[Text Word] OR imaging diagnosis [Text Word] OR pathology[Text Word].Methods of Study SelectionArticles published in English that addressed adenomyosis and discussed prevalence, diagnosis, and symptoms were included. The included articles described pathology diagnosis, imaging, biopsy diagnosis, prevalence and age of onset, symptoms, and concomitant endometriosis.Tabulation, Integration, and ResultsSixteen articles were included in the qualitative analysis. The studies are heterogeneous when diagnosing adenomyosis with differing criteria, protocols, and patient populations. The prevalence estimates range from 20% to 88.8% in women who are symptomatic (average 30%–35%), with most diagnosed between the ages of 32 years and 38 years. The correlation between imaging and pathology continues to evolve. As imaging advances, newer studies report that younger women who are symptomatic are being diagnosed with adenomyosis on the basis of both magnetic resonance imaging and/or transvaginal ultrasound. High rates of concomitant endometriosis create challenges when discerning the etiology of pelvic pain. Symptoms that are historically attributed to endometriosis may actually be caused by adenomyosis.ConclusionAdenomyosis remains a challenge to identify, assess, and research because of the lack of standardized diagnostic criteria, especially in women who wish to retain their uterus. As noninvasive diagnostics such as imaging and myometrial biopsies continue to improve, younger women with variable symptoms will likely create criteria for diagnosis with adenomyosis. The priority should be to create standardized histopathologic and imaging diagnoses to gain a deeper understanding of adenomyosis.     

子宫内膜异位症和子宫腺肌病的诊断与分型

子宫内膜异位症和子宫腺肌病是子宫内膜生长在子宫腔以外形成病灶、引起症状和体征的一类疾病。痛经、不孕、性交痛、盆腔包块、子宫直肠窝触痛结节是其主要表现。超声和MRI对子宫内膜异位症和子宫腺肌病的诊断非常有帮助,腹腔镜应作为主要手术治疗手段。到目前为止,还没有对子宫内膜异位症提出统一的分类标准。     

The pathogenesis of bladder detrusor endometriosis

OBJECTIVE: The purpose of this study was to ascertain whether bladder detrusor endometriosis originates intraperitoneally in the vesicouterine pouch or subperitoneally in the vesicovaginal septum and whether an association exists with uterine adenomyosis. STUDY DESIGN: Data were collected on clinical, diagnostic, and surgical characteristics of 40 women who were evaluated for primary, histologically confirmed, full-thickness detrusor endometriosis. RESULTS: In 19 of the 20 women who underwent surgery, the anterouterine pouch was partially or totally obliterated with the nodule that was located in the posterior wall or dome of the bladder, well above the uterine isthmus, and adherent to the anterior uterine wall or fundus. With one exception, pelvic ultrasonography, cystoscopy, intravenous pyelography, magnetic resonance imaging, and computed tomography identified the lesion cranially with respect to the vesicovaginal septum and excluded uterine adenomyosis. CONCLUSION: Vesical endometriosis seems to originate from the implantation of regurgitated endometrial cells in the anterior cul-de-sac and not to be associated with uterine adenomyosis. The metaplasia of subperitoneal mullerian remnants and the uterus-vesical adenomyosis extension theories are not compatible with most imaging, surgical, and pathologic findings.     

盆腔良性肿物伴血清CA125水平升高的临床意义

目的探讨血清CA125水平在妇科良性肿瘤、结核性肿物及其他炎症性肿物、子宫内膜异位症等盆腔良性肿物中的升高情况及临床意义.方法回顾性分析中国医学科学院中国协和医科大学肿瘤医院于1999年1月-2003年12月间收治并经病理检查证实的492例妇科盆腔良性肿物患者的临床资料,其中卵巢良性肿瘤237例,其他盆腔良性肿物如子宫肌瘤、子宫腺肌病、卵巢子宫内膜异位症、盆腔结核及其他炎症性肿物等共255例,所有患者术前均有血清CA125的检测.另随机选取60例卵巢上皮性癌患者作为对照.结果盆腔结核、子宫腺肌病、卵巢子宫内膜异位症及卵泡膜-纤维组肿瘤患者的血清CA125水平中位数值均高于正常值(35 kU/L以下),分别是465.0、88.9、59.0、44.5 kU/L.本组盆腔良性肿物中, 血清CA125水平单例最高值为卵泡膜-纤维组肿瘤(1281.0 kU/L),中位数值最高者为盆腔结核(465.0 kU/L).60例卵巢上皮性癌患者血清CA125水平升高者达95.0%,其中位数值是755.5 kU/L,与良性肿物相比,差异有统计学意义(P<0.01 ).在子宫肌瘤与子宫腺肌病的鉴别诊断中,以血清CA125≥50 kU/L为标准,诊断子宫腺肌病的敏感性、特异性、阳性预测值及阴性预测值相对较高,分别是72%、94%、79%和91%.结论血清CA125水平升高也可见于一些盆腔良性肿物,主要有盆腔结核、子宫腺肌病、卵巢子宫内膜异位症及卵泡膜-纤维组肿瘤等,但其中位数值均明显低于卵巢上皮性癌.血清CA125水平检测有利于子宫肌瘤和子宫腺肌病的鉴别诊断.     

Usefulness of measurement of serum CA125 levels in diagnosing and treating endometriosis

We investigated the usefulness of the measurement of serum CA125 levels for the diagnosis and therapeutic monitoring of endometriosis. An additional study concentrated on the production of CA125. 1. Elevated levels of serum CA125 were noted in 52 of 66 patients with endometriosis in which the positive rate was 78.8% and mean was 119.8 U/ml. The mean value and positive rate of serum CA125 levels in patients with adenomyosis were higher than those in pelvic endometriosis. 2. The correlation between preoperative serum CA125 levels and the extracted tissue weight was statistically significant. The tissue concentration of CA125 of adenomyosis was 1,479.3 +/- 1,087.1 U/g and that of pelvic endometriosis was 309.7 +/- 23.1 U/g wet weight. 3. The serum CA125 levels in patients with adenomyosis fell postoperatively, and all were below 35 U/ml within two weeks. The serum CA125 levels were below 35 U/ml in 13 out of 15 patients (86.7%) with pelvic endometriosis treated with danazol and the change in the serum CA125 levels was closely related to the clinical course. 4. Clinicopathological states with a high level of serum CA125 were observed in patients with normal and ectopic pregnancy, puerperium, ovarian hyperstimulation syndrome (OHSS) and peritonitis. It was concluded that the measurement of serum CA125 levels was useful in the diagnosis and therapeutic monitoring of endometriosis, and CA125 might be produced and/or secreted not only from the endometrium but also from the peritoneum.     

The role of magnetic resonance imaging in minimal access surgery

PURPOSE OF REVIEW: Magnetic resonance imaging is commonly used for gynaecological malignancies, but also is increasingly used for the investigation of benign gynaecological complaints. This review summarizes the current evidence regarding its use as an adjunct to minimal access surgery for endometriosis, adenomyosis, adhesions and fibroids. RECENT FINDINGS: Magnetic resonance imaging appears to be equal in efficacy to ultrasound for the diagnosis of both fibroids and endometriosis, and perhaps superior for the diagnosis of adenomyosis. It is extremely useful for the preoperative investigation of severe endometriosis, especially recto-vaginal disease. Milder endometriosis is, however, still difficult to diagnose by either ultrasound or magnetic resonance imaging. Magnetic resonance imaging can also be helpful for the detection of adhesions, pelvic collections, congenital defects and fibroids. It is also useful following fibroid embolization. SUMMARY: Currently, it is not cost-effective to use magnetic resonance imaging as the modality of first choice when investigating pelvic pain and or menstrual disorders. If preoperative patients are carefully selected, however, it can substantially reduce surgical morbidity by using it to diagnose severe endometriosis and adhesions which may lead to cost savings overall.     

Adenomyosis and reproduction

Evidence has been provided that pelvic endometriosis is significantly associated with uterine adenomyosis and that the latter constitutes the major factor of infertility in such conditions. Furthermore, it has become evident that both adenomyosis and endometriosis constitute a pathophysiological and nosological entity. Mild peritoneal endometriosis of the fertile woman and premenopausal adenomyosis of the parous and non-parous woman, as well as adenomyosis in association with endometriosis of the infertile woman, constitute a pathophysiological continuum that is characterized by the dislocation of basal endometrium. Due to the postponement of childbearing late into the period of reproduction, premenopausal adenomyosis might increasingly become a factor for infertility in addition to adenomyosis associated with endometriosis of younger women. In any event, the presence or absence of uterine adenomyosis should be examined in a sterility work-up.     

Is adenomyosis the neglected phenotype of an endomyometrial dysfunction syndrome?

Since the dissociation between adenomyoma and endometriosis in the 1920s and the laparoscopic progress in the diagnosis and surgery of endometriosis, the literature has been greatly focused on the disease endometriosis. The study of adenomyosis, on the other hand, has been neglected as the diagnosis remained based on hysterectomy specimens. However, since the introduction of magnetic resonance and sonographic imaging techniques in the 1980s, the myometrial junctional zone has been identified as a third uterine zone and interest in adenomyosis was renewed. This has also been the start for the interest in the role of the myometrial junctional zone dysfunction and adenomyosis in reproductive and obstetrical disorders.     

Ultrasonography for the diagnosis of adenomyosis

An accurate preoperative diagnosis of uterine adenomyosis is often difficult. We reviewed our experience with ultrasound evaluation of this pathological entity. Patients with histologically proven adenomyosis were studied to determine the usefulness of ultrasound for the preoperative diagnosis of this entity. In patients with adenomyosis, variable ultrasound patterns are seen, namely, enlargement of the uterus, irregular vesicular spaces within the myometrium, and an acoustically enhanced posterior wall of the uterus. However, leiomyoma had a similar echopattern. Based on five cases of histologically extensive adenomyoasis, an accurate diagnosis of adenomyosis proved feasible when ultrasonography showed all three ultrasonic patterns mentioned above, associated with a retroverted uterus or possible adhesions between the uterus and structures in close proximity, nodule or outgrowth in the region of the uterosacral ligaments or in combination, as frequently found in conjunction with external endometriosis. The ultrasonographical demonstration of endometrial cyst of the ovary may contribute to an accurate diagnosis of adenomyosis.     

Adenomyosis as a disorder of the early and late human reproductive period

Magnetic resonance imaging (MRI) allows the diagnosis of adenomyosis in vivo with a high sensitivity and specificity. Usually the diagnosis of adenomyosis is obtained from women in their fourth to fifth decade of life. However, recent data suggest that adenomyosis may develop much sooner in life, particularly in women with endometriosis. In order to test these suggestions, MRI of the uterus in 227 women with and without endometriosis was performed and the results were related to the age of the subjects (age groups: 17-24, 25-29, 30-34 and >34 years). The study revealed that the process of the development of adenomyosis, represented by an increased diameter of the dorsal junctional zone of the uterus as the imaging correlative of the invasion of basal endometrium into the junctional zone, had already commenced early in the third decade of life and progressed steadily during the fourth decade in women with endometriosis. Women without endometriosis showed almost no signs of adenomyosis up to the age of 34 years. Surprisingly, parallel in both groups of women, a marked increase in the incidence of adenomyosis could be observed beyond the age of 34 years, thus representing a common phenomenon in the age-related pathophysiological continuum of adenomyosis.     

Adenomyosis a variant, not a disease? Evidence from hysterectomized menopausal women in the Study of Women's Health Across the Nation (SWAN)

OBJECTIVE: Our study evaluates the symptoms commonly attributed to adenomyosis in women undergoing the menopausal transition. We hypothesized that adenomyosis is more commonly seen in women with fibroids, pelvic pain, abnormal uterine bleeding, and in the presence of endometriosis. DESIGN: Retrospective cohort. SETTING: Multisite community-based study. PATIENT(S): Enrollees in the Study of Women's Health Across the Nation who had hysterectomies. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Relationship of adenomyosis to presenting symptoms and other patient characteristics. RESULT(S): Adenomyosis was found in 48% of 137 patients. Frequencies of presenting symptoms were similar in those with and without evidence of adenomyosis. The same prevalence of fibroids was seen in the presence or absence of adenomyosis: 37% versus 43%, endometriosis, 3% versus 5%, abnormal bleeding, 27% versus 33%, or chronic pelvic pain in the presence of fibroids 12% versus 17%. CONCLUSION(S): Adenomyosis is a common diagnosis seen in hysterectomized specimens from women undergoing the perimenopausal transition. Adenomyosis is equally common in women who also have fibroids, endometriosis, pelvic pain, or abnormal uterine bleeding, and women who do not. Therefore, adenomyosis is an incidental finding, not the source of the symptomatology. It appears not to be a "disease" per se but rather a normal variant.     

Transvaginal ultrasound or MRI for diagnosis of adenomyosis

PURPOSE OF REVIEW: Transvaginal ultrasound and MRI are used to diagnose adenomyosis. This review summarizes the current evidence on the diagnostic accuracy of these techniques. RECENT FINDINGS: The image resolution of both transvaginal ultrasound and MRI is effective for the diagnosis of adenomyosis. In a limited number of well-designed studies the diagnostic efficiency of MRI and transvaginal ultrasound were almost in line. With transvaginal ultrasound, considerable training is needed to recognize the distinct ultrasound pattern in the diagnosis of adenomyosis. The findings in MRI are less observer dependent, but still somewhat dependent on an MRI observer who is expert in gynecologic imaging. SUMMARY: Transvaginal ultrasound is the natural first choice of image modality when investigating pelvic pain or menstrual disorders, but correct diagnosis of adenomyosis is dependent on sonographers trained in pattern recognition of adenomyosis. When transvaginal ultrasound provides indefinite findings or when dealing with difficult cases with coexistence of other abnormalities (myomas and severe endometriosis), MRI may add information and increase the diagnostic performance.     

Adenomyosis in the Adolescent Population: A Case Report and Review of the Literature

BackgroundThis report presents a rare cause of dysmenorrhea in the adolescent female and the usefulness of magnetic resonance imaging (MRI) with T2 weighted sequence in the identification of adenomyosis.CaseTwo adolescents who presented with persistent pelvic pain in the absence of outflow tract obstruction or biopsy confirmed endometriosis had MRI-findings consistent with adenomyosis.Summary and ConclusionIn the adolescent female presenting with persistent dysmenorrhea, a diagnosis of adenomyosis is rare but should remain a possibility as one considers the differential diagnosis.     

Non-invasive methods of diagnosis of endometriosis

PURPOSE OF REVIEW: Laparoscopy is the gold standard for the diagnosis of endometriosis but the need for visual evidence of the disease is a major stumbling-block for both effective clinical management of affected patients as well as for research into this common and debilitating reproductive disease. Laparoscopy is invasive and often causes a delay in diagnosis and treatment, especially in symptomatic teenagers and young women. Moreover, the visual inspection of the pelvis has major limitations, particularly for the diagnosis of retroperitoneal lesions. It is therefore not surprising that considerable efforts are being made to improve imaging techniques and to evaluate the diagnostic value of potential molecular markers of disease. RECENT FINDINGS: High-resolution transvaginal ultrasonography and, in selected cases, magnetic resonance imaging improve the diagnosis of retroperitoneal pelvic endometriosis as well as the identification of lesions that involve pelvic organs. A variety of serum and endometrial markers are being evaluated for their diagnostic potential, particularly in endometriosis associated infertility. The first gene profiling studies are showing positive results and proteomic technology is being applied to identify novel diagnostic protein expression patterns. SUMMARY: Current imaging techniques, such as transvaginal ultrasonography, are useful to screen the pelvis for the presence of retroperitoneal endometriosis but fail to diagnose peritoneal lesions, small ovarian endometriomas and adhesions. Postgenomic technologies and identification of novel serum and endometrial markers are likely to revolutionize future diagnosis of endometriosis.     

Endometriosis and adenomyosis

Peristaltic activity of the non-pregnant uterus serves fundamental functions in the early process of reproduction. Hyperperistalsis of the uterus is significantly associated with the development of endometriosis and adenomyosis. In women with hyperperistalsis fragments of basal endometrium are detached during menstruation and transported into the peritoneal cavity. Fragments of basal endometrium have an increased potential of implantation and proliferation resulting in pelvic endometriosis. In addition, hyperperistalsis induces the proliferation of basal endometrium into myometrial dehiscencies. This results in endometriosis-associated adenomyosis with a prevalence of about 90%. Adenomyosis results in impaired directed sperm transport and thus constitutes an important cause of sterility in women with endometriosis. The principal mechanism of endometriosis/adenomyosis is the paracrine interference of endometrial estrogen with the cyclical endocrine control of archimyometrial peristalsis exerted by the ovary thus resulting in hyperperistalsis. Minimal endometriosis of the fertile women, endometriosis and adenomyosis of the infertile women and adenomyosis of the parous peri- and postmenopausal women are considered as phenotypes of a pathophysiological continuum with uterine peristalsis playing a prominent role.     

不同糖耐量状态肥胖儿童血清脂联素的变化及其临床意义

目的了解不同葡萄糖耐量状态的肥胖儿童血清脂联素水平，探讨其与年 龄、体重指数(BMI)、血脂、血糖及胰岛素水平的关系。 方法选择2002~2004年于广州市儿童医院初诊并住院诊治的肥胖儿童52例，分为36例糖耐量正常(NGT)肥胖组和16例糖耐量受损(IGT)肥胖组。测定两组肥胖儿童和41例年龄、性别匹配的正常儿童空腹血清脂联素、胆固醇(CHO)、甘油三酯(TG)、低密度脂蛋白胆固醇(LDL C)、血糖和胰岛素(FINS)，计算胰岛素抵抗指数(HOMA IR)。肥胖组儿童均做口服葡萄糖耐量试验(OGTT)，测定OGTT 2h血糖和胰岛素。 结果正常对照组、NGT肥胖组及IGT肥胖组血清脂联素水平依次降低，HOMA IR依次升高，且均有统计学意义；相关性分析显示肥胖儿童血清脂联素与TG、LDL C、FINS呈显著负相关(P<005)。 结论肥胖儿童血清脂联素水平降低，并与血脂、胰岛素抵抗密切相关；与NGT肥胖组相比，IGT肥胖组儿童的血清脂联素水平进一步降低。     

阴道超声对诊断治疗卵巢子宫内膜异位囊肿及子宫腺肌病的价值

目的探讨阴道超声及血清CA125测定对诊断治疗卵巢子宫内膜异位囊肿及子宫腺肌病的价值。方法对卵巢子宫内膜异位囊肿及子宫腺肌病患者631例进行回顾性分析，术前均经阴道超声检查，部分患者进行了血清CA125测定。结果阴道超声检查卵巢子宫内膜异位囊肿符合率98．7％；子宫腺肌病符合率91．7％；卵巢子宫内膜异位囊肿合并子宫腺肌病符合率95．1％。血清CA125检查卵巢子宫内膜异位囊肿，阳性率39．4％；子宫腺肌病阳性率52．2％；卵巢子宫内膜异位囊肿合并子宫腺肌病阳性率59．2％。结论阴道超声可做为较准确诊断卵巢子宫内膜异位囊肿及子宫腺肌病的首选方法。阴道超声下囊肿穿刺是治疗卵巢子宫内膜异位囊肿的简便、有效的方法之一。血清CA125测定可做为卵巢子宫内膜异位囊肿及子宫腺肌病的协助诊断方法，应进一步完善对照组的研究。     

Evaluating chronic pelvic pain. A consensus recommendation. Pelvic Pain Expert Working Group

OBJECTIVE: To identify a comprehensive approach to evaluating women with chronic pelvic pain based on findings in the literature. STUDY DESIGN: A working group of gynecologist pelvic pain specialists was convened to consider principles on which consensus could be reached and to identify areas in which consensus is not yet possible. RESULTS: Chronic pelvic pain affects 15% of American women. The diagnostic and therapeutic approach to the complaint may be influenced inordinately by the specialty of the practitioner to whom the woman presents. A comprehensive approach to the complaint requires recognition of the multiple organ systems that may be involved. Evaluation of the woman with chronic pelvic pain begins with a comprehensive history and physical examination, followed by selected laboratory and imaging studies. For those women in whom the evaluation does not yield a likely cause of the complaint, the empiric use of nonsteroidal antiinflammatory agents, oral contraceptives, and perhaps antibiotics or antispasmodics is indicated. Women who fail to respond to empiric therapy should be considered highly likely to have endometriosis or adenomyosis. Further diagnostic (laparoscopy) or therapeutic (gonadotropin-releasing hormone agonist) interventions should be directed toward the high likelihood of endometriosis or adenomyosis. CONCLUSION: A comprehensive approach to chronic pelvic pain includes consideration of multiple organ systems, with empiric therapy appropriate after a thorough history and physical examination, to further delineate the pain problem.     

Sonographic Evaluation for Endometriosis in Routine Pelvic Ultrasound

Study ObjectiveTo show how the evaluation for endometriosis can be included in the routine pelvic ultrasound examination.DesignStepwise narrated video demonstration of the sonographic evaluation for endometriosis in routine pelvic ultrasound following the recommended sonographic approach published in the 2016 consensus paper by the International Deep Endometriosis Analysis (IDEA) group [1].SettingEndometriosis is a common and often debilitating gynecological disorder that affects 5–10% of women [2]. The prevalence is even higher among women with symptoms of endometriosis [2], which include chronic pelvic pain, acquired dysmenorrhea, dyspareunia, dyschezia, menorrhagia, abnormal bleeding, and infertility. Approximately 80% of women who have endometriosis have superficial lesions, whereas 20% have deep infiltrating endometriosis (DIE; [3]). Laparoscopy is the gold standard for diagnosing endometriosis, because it allows the diagnosis of all forms of endometriosis and often immediate removal of superficial endometriosis. The removal of DIE is considerably more complicated and usually cannot be completed unless it was diagnosed preoperatively. The technique to diagnose DIE with transvaginal ultrasound (TVUS) was first described in detail in 2009 [4]. Since then, the accuracy of TVUS for the prediction of DIE has been well established in the literature 5, 6, 7. TVUS is widely used as a first-line investigation for women with gynecological symptoms. The inclusion of an assessment for endometriosis in the routine pelvic ultrasound allows earlier diagnosis and better surgical outcomes for all women with DIE.InterventionsThe evaluation for endometriosis in routine pelvic ultrasound based on the IDEA consensus promotes a 4-step dynamic ultrasound approach [1]: (1) routine evaluation of uterus and adnexa with particular attention for sonographic signs of adenomyosis and the presence or absence of endometriomas; (2) evaluation of transvaginal sonographic ‘soft markers’ such as site-specific tenderness and ovarian mobility; (3) assessment of status of pouch of Douglas using the real-time ultrasound-based “sliding sign;” and (4) assessment of DIE nodules in the anterior and posterior compartments, which involves assessment of the bladder, vaginal vault, uterosacral ligaments, and bowel, including rectum, rectosigmoid junction, and sigmoid colon. Because 5–10% of women with DIE also have ureteric endometriosis, it is useful to assess the kidneys. Silent hydronephrosis is easily identified in 50–60% of patients with ureteric involvement. Although it is possible to identify DIE involving the ureters more directly, this requires more advanced skills, and further studies are still needed to better define the accuracy of ureteric DIE detection by TVUS 8, 9, 10.ConclusionTraditionally, only pathologies of the uterus and ovaries are assessed during a routine pelvic ultrasound. Here we demonstrate that the routine ultrasound examination can easily be extended beyond the uterus and ovaries into the posterior and anterior pelvic compartments to evaluate structural mobility and to look for deep infiltrating endometriotic nodules, wherewith women suffering from DIE can benefit from a preoperative diagnosis and subsequently, a single, well-planned procedure in the hands of a well-prepared team.