# The assessment of association between endometrioma size and other endometriosis compartments according to #ENZIAN classification

## TL;DR

This study finds that smaller endometriomas are linked to more widespread pelvic disease, while larger ones suggest a more localized condition, supporting the use of the #ENZIAN classification for better surgical planning.

## Contribution

The study introduces new evidence linking endometrioma size to disease extent using the #ENZIAN classification system.

## Key findings

- Smaller endometriomas (O1/2) are associated with higher rates of adenomyosis and rectal involvement.
- Larger endometriomas (O3) are more likely to be unilateral and occur in younger women.
- The #ENZIAN classification helps distinguish between localized and widespread endometriosis phenotypes.

## Abstract

Endometriomas are common in endometriosis and may coexist with deep pelvic disease. This study aimed to assess the association between endometrioma size and other endometriosis localizations using the #ENZIAN classification.

This multicenter study included women who underwent laparoscopic surgery for endometriomas between 2021 and 2024, with available surgical reports defining the #ENZIAN classification. Endometriomas were categorized as O1/2 (< 7 cm) or O3 (≥ 7 cm). Other endometriosis localizations were compared between the study groups.

A total of 269 women underwent surgery for endometriosis involving endometriomas. Of these, 42 had #ENZIAN O3 endometriomas, with a significantly higher rate of unilateral cysts compared to women with #ENZIAN O1/2 (92.8% vs. 68.2%, p = 0.0011). After excluding bilateral cases, 194 women with unilateral endometriomas were analyzed: 39 with #ENZIAN O3 and 155 with #ENZIAN O1/2. Women with O3 lesions were significantly younger (31.5 ± 5.9 vs. 34.5 ± 6.6 years; p = 0.011). The rate of adenomyosis (#ENZIAN F-A) was significantly lower in the O3 group (41% vs. 69%, p = 0.0012), as was rectal involvement (#ENZIAN C; 7.7% vs. 23.8%, p = 0.025). The prevalence of severe pelvic wall disease (T/B ≥ 2) did not differ significantly between groups.

Smaller endometriomas (O1/2) are associated with more extensive pelvic disease, including higher rates of adenomyosis, rectal involvement, and pelvic adhesions, whereas larger endometriomas (O3) may represent a more localized disease phenotype. These findings support the use of the #ENZIAN classification for more accurate preoperative assessment and individualized surgical planning.