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Endometriosis affects a significant number of young premenopausal women. Quite apart from the medical challenges, endometriosis is a relevant burden for healthcare and social security systems. Standardized quality indicators for the treatment of endometriosis have not previously been systematically verified. The three-stage study QS ENDO was initiated to record and improve the reality and quality of care. One of its aims is to create quality indicators for the diagnosis and treatment of endometriosis. For the first stage of QS ENDO Real, letters were sent to all 1014 gynecological departments in the German-speaking area of Europe (the DACH region) which included a questionnaire as a means of surveying the current state of care. A total of 296 (29.2%) of the centers which received the questionnaire participated in the survey. The subsequent evaluation of the completed questionnaires showed that the majority of patients with endometriosis (around 60%, based on estimates from the data) are not treated in hospitals which have been certified by the SEF. The guidelines recommend the use of specific classification systems (rASRM, ENZIAN) but, depending on the level of care offered by the hospital, only around 44.4 to 66.4% of departments used the rASRM score and only 27% of hospitals used the ENZIAN classification system to describe deep-infiltrating endometriosis. When taking patientsʼ medical history, some centers (6.6 – 17.9%) considered questions about leading symptoms such as dyschezia, dysuria and dyspareunia to be unimportant. QS ENDO Real has made it possible, for the first time, to get an overview of the reality of care provided to patients with endometriosis in the German-speaking areas of Europe. The findings indicate that several of the measures recommended in international guidelines as the gold standard of care are only used to treat some of the patients. In this respect, more efforts will be needed to provide more advanced training. The approach used for treatment must be guideline-based, also in not-certified centers, to improve the quality of care in the treatment of patients with endometriosis.

Advances in preoperative diagnostics as well as in surgical techniques for the treatment of endometriosis, especially for deep endometriosis, call for a classification system, that includes all aspects of the disease such as peritoneal endometriosis, ovarian endometriosis, deep endometriosis, and secondary adhesions. The widely accepted revised American Society for Reproductive Medicine classification (rASRM) has certain limitations because of its incomplete description of deep endometriosis. In contrast, the Enzian classification, which has been implemented in the last decade, has proved to be the most suitable tool for staging deep endometriosis, but does not include peritoneal or ovarian disease or adhesions. To overcome these limitations, a comprehensive classification system for complete mapping of endometriosis, including anatomical location, size of the lesions, adhesions and degree of involvement of the adjacent organs, that can be used with both diagnostic and surgical methods, has been created through a consensus process and will be described in detail—the #Enzian classification.

Die Endometriose ist eine chronisch rezidivierende und systemische Erkrankung. Deshalb schutzen weder medikamentose noch operative Therapien vor Rezidiven. Wiederholte, intermittierende oder auch langdauernde medikamentose Behandlungen sind oft notwendig. In deren Rahmen kommt es nicht nur auf die Wirksamkeit der jeweiligen Substanz hinsichtlich der Endometrioseregression an. Auch Schmerzbeseitigung, Vertraglichkeit und individuelle Nebenwirkungen sind fur die Praxis relevante Entscheidungskriterien.

In the case of infertility the macroscopically and/or histologically confirmed diagnosis of endometriosis alone is not an indication for surgical or medical treatment of endometriosis. Treatment is necessary only when additional clinical symptoms of pain caused by the disease, active proliferative implants, severe mechanical disturbances of Fallopian tubes and ovaries, or deep infiltration endometriosis is judged as a relevant cause of sterility. The presence of implants alone – especially in mild or minimal stages – is probably an accidental finding with no correlation to the infertility problems. The therapeutic options are surgical – mainly endoscopic surgery – medical or a combination of both. Regression of the implants and shrinkage of the cysts can be achieved with medically induced ovarian suppression. Clinical trials have demonstrated that high doses of progestins, Danazol and GnRH agonists are effective. Because low differentiated types of endometriosis and deep infiltration nodules can only be influenced with permanent estrogen deprivation, an endoscopic surgical procedure– resection, coagulation or vaporisation of endometriotic tissue, plus resection of adhesions and fibrosis – is the main therapeutic principle. Because microscopic implants and deep infiltration foci surrounded by fibrosis can not be treated sufficiently with endoscopic surgery alone, an individual therapeutic strategy must be adopted in each case of endometriosis and infertility. Taking in account the age of the patient, the duration of infertility, and other factors we have to consider medical and/or surgical treatment of endometriosis.

Aim: We present our experience with diagnosing and treating 22 cases of urinary tract endometriosis in women of reproductive age. Patients and Methods: From January 2001 to January 2003, 22 women of reproductive age (mean age 34.8 years) were diagnosed suffering from endometriosis of the urinary tract. We used the Endoscopic Endometriosis Classification (EEC) for assessing the stage of endometriosis. Results: Endometriosis was present in the bladder, the lower third of the ureter, and in a postnephrectomy ureteral stump in 15 (68.1%), six (27.2%) and one (4.5%) cases, respectively. The EEC classification revealed stages I, II, III and IV in four (18.1%), one (4.5%), one (4.5%), and 16 (72.7%) patients, respectively. Urinary symptoms were present in 14 (63.6%) patients. For the treatment of bladder endometriosis, 10 patients underwent partial cystectomy, while the remaining five patients were treated with transurethral resection. In four patients ureterolysis was performed, by laparoscopy in two cases and by open surgery in the other two cases. Ureterectomy and re-implantation with bladder psoas hitching took place in six patients. In the case of endometriosis of the ureteral stump, open surgical excision took place. During the mean follow-up period of 20 months (range 16–40) no long-term complication or relapse was diagnosed. Conclusions: Bladder and ureteral endometriosis should be considered in women of reproductive age with non-specific urinary tract or abdominal symptoms, and surgical treatment is recommended.

Oral progestins have been reported to be effective in the treatment of endometriosis. The mode of action is still a matter of debate, but it may involve modulation of mitotic activity, local growth factors and growth factor receptors, as well as other paracrine mechanisms and anti-inflammatory reactions. Other treatments such as danazol and GnRH-agonists are effective with regard to relief of symptoms and regression of the endometriotic implants, but are associated with high recurrence rates and a wide range of side effects. Progestins are therefore indicated in the symptomatic management of pain, bleeding disorders and other symptoms caused by endometriosis when long-term medication or repeated courses of treatment are indicated. The relationship between costs and efficacy is good, and the side effects are tolerable in most cases. Dydrogesterone is particularly suitable in cases where the woman desires to become pregnant and to prevent bleeding problems. Only very limited data are available concerning the use of progestins in adenomyosis and no conclusions can be drawn.

Oral progestins, without an estrogen component, have been reported to be effective in the treatment of endometriosis, but not adenomyosis or myomas. The mode of action on the target tissue is still a matter of debate. Besides the importance of estrogens for the development and growth of endometriosis and myomas, progesterone seems to play an important role in the modulation of mitotic activity, local growth factors and growth factor receptors, as well as other paracrine mechanisms. Earlier studies postulated activities via steroid receptor mechanisms, as observed in the uterine mucosa and myometrium. Recent studies, however, have raised some doubts about this hypothesis. Effective new therapies for endometriosis have been introduced during the last 30 years and progestins now have a place in the symptomatic management of pain, bleeding and other symptoms caused by endometriosis, adenomyosis or myoma, particularly when long-term medication is indicated or when repeated courses of treatment are acceptable.

Objective: In vitro studies demonstrated that implantation on membranes (peritoneum, amniotic membranes) can take place if there are defects on the surface of the membranes. If these mechanisms play a role for the development of endometriosis in vivo, then patients with surgical treatment of peritoneal endometriosis in the luteal phase must have a high recurrence rate. Design: Retrospective analysis of operation charts and follow-up data. Setting: Department of gynecology, in a hospital-based endometriosis treatment center. Patient(s): Two hundred twenty premenopausal women. Intervention(s): Laparoscopic treatment for peritoneal endometriosis, stage I and II by revised American Society for Reproductive Medicine guidelines. Main Outcome Measure(s): During the follow-up period of 2 years, symptoms and gynecological and sonographic findings were documented. In case of suspected recurrence a repeat laparoscopy with biopsy was performed to prove the recurrent endometriosis macroscopically and histologically. Result(s): The total recurrence rate after 2 years was 9.6%. The recurrence rate of group III (15%) was twice as high as those of group I (7%) and group II (8%), as indicated by subjective complaints, clinical findings, macroscopy, and histology; no differences were found between groups I and II. Conclusion(s): Endoscopic surgery for the treatment of peritoneal endometriosis should not be performed in the luteal phase.

Ultrastructural features of endometriotic implants suggest an incomplete response to the prevalent hormonal milieu. The cyclic changes, especially in the secretory phase, appear to depend more on the morphologic differentiation of the ectopic implants than on the hormonal stimulus. The endometriotic tissue encompassed a wide range of morphologic development from poorly to highly differentiated glands. Variations occurred from gland to gland and even within the same gland. Complete proliferative development was found only in some of the patients and full secretory transformation was absent in all. The incomplete morphologic response to cyclic hormonal changes may explain the frequent failure of endocrine therapy.

Electron microscopic examinations were carried out on 29 representative endometriotic glands obtained from 16 biopsies. Patients with endometriosis diagnosed by laparoscopy and confirmed by laparoscopic biopsy prior to hormonal treatment received danazol, 800 mg daily. The tissue samples were obtained after 2, 4, and 6 months of usage of the drug to study the ultrastructural effect of this treatment. The glandular epithelium appeared to be arrested in what looked like the late proliferative stage of the normal menstrual cycle. The ciliated cells remained unchanged for the most part. The findings were correlated with possible effects of danazol on the target tissue, but caution is required in the interpretation of ultrastructural effects of steroids until detailed knowledge of the metabolic pathways is available.

Transmission electron microscopy and ultracytochemical localization of alkaline phosphatase were employed to compare the glands of the isthmic mucosa with those of the fundal endometrium. Examination of 40 biopsies during various phases of the menstrual cycle and in the postmenopause have demonstrated the features of this transitional mucosa. The cyclic morphologic changes in the isthmus are almost identical with those of the glands of the basalis of the corpus. Alkaline phosphatase was demonstrated consistently on the plasma membranes of the isthmic mucosa but not on those of the glands of the basalis; technical considerations may in part explain these differences. Secretory activity was found in every phase of the cycle. The data from postmenopausal patients suggest the concept of migration of the isthmic mucosa toward the corpus uteri above the internal anatomical os.