{"paper_id":"27c4761d-8d19-48fd-b9f1-a22e1a37a971","body_text":"17\nMold J Health Sci. 2024;11(2):17-26Deep endometriosis and quality of life\nRESEARCH ARTICLE\nDeep endometriosis – diagnosis and impact on quality of life\nElena Ivanova*, Nadejda Codreanu\nDepartment of Obstetrics and Gynecology, Nicolae Testemiţanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova\nABSTRACT\nUDC: 618.145-007.415-07\nhttps://doi.org/10.52645/MJHS.2024.2.03\nCite this article: Ivanova E, Codreanu N. Deep endometriosis – diagnosis and impact on quality of life. Mold J Health Sci. 2024;11(2):17-26. https://doi.\norg/10.52645/MJHS.2024.2.03.\nIntroduction. Deep infiltrating endometriosis (DIE) is considered the most painful form of endometriosis, responsible for \nreducing the women’s quality of life (QoL). Its management presents difficulties in medicine. The #Enzian classification \nreflects locations of DIE and simplifies its medical management. International guidelines recommend studies of QoL in \nwomen with endometriosis.\nObjective. To investigate the symptoms of DIE and determine its impact on QoL to optimize its diagnostics.\nMaterials and methods. A cohort study was conducted over 2 years at the Gheorghe Paladi Municipal Clinical Hospital, in-\ncluding 190 patients with endometriosis, who were divided into groups: main group - 85 patients with DIE, control group \n- 105 other endometriosis forms. To objectify the pain, Visual Analog Scale and Biberoglu and Behrman (B&B) were used. \nEndometriosis was staged with the #Enzian classification. For the analysis of QoL, three standardized questionnaires were \nused. Data were recorded in Excel and statistically calculated with the SPSS program.\nResults. Pelvic pain syndrome according to the Visual Analog Scale and B&B scales in the main group was 3 times more \npronounced than in the control group (p < 0.01). Lesions of DIE according to the #Enzian statistically correlated with \nchronic pelvic pain, dysmenorrhea, dyspareunia, dysuria, dyschezia >7 points (VAS), catamenial rectal tenesmus, defeca -\ntion disorders, menometrorrhagia, hematuria, bladder tenesmus, hydronephrosis with ureteral stenting during pregnancy, \ncatamenial cough and hemoptysis, chest pain and spontaneous pneumothorax, hemorrhagic scar, hiccups, and the frenicus \nsymptom (p < 0.05). According to the questionnaires of QoL, DIE significantly influences life determinants by 44.27%, \ncompared to the control group at 3.64% (p < 0.01), allowing realization of life determinants in a maximum of 58.54% vs. \nthe control group’s 92.18% (p < 0.01). Additionally, psychological well-being in patients with DIE is lower than that in the \ncontrol group (44.29% vs. 81.38%, p < 0.01).\nConclusions. High-intensity pain syndrome and extragenital symptoms correlated with compartments of #Enzian will \nassist in the preoperative multidisciplinary diagnosis of DIE.  The high influence on life determinants, the low realization of \nlife potential, and the low psychological well-being confirm the significant impact of DIE on QoL, classifying it as a disability.\nKeywords: endometriosis, deep endometriosis, diagnosis, pelvic pain, quality of life.\nManuscript received: 14.03.2024\nAccepted for publication: 17.04.2024\nPublished: 20.06.2024\n*Corresponding author: Elena Ivanova, PhD fellow, \nDepartment of Obstetrics and Gynecology, \nNicolae Testemiţanu State University of Medicine and Pharmacy, \nChisinau, Republic of Moldova\n165, Stefan cel Mare si Sfant blvd., MD-2004\ne-mail: elle.ivanova.90@gmail.com\nAuthors’ ORCID IDs\nElena Ivanova – https://orcid.org/0000-0001-8460-9849\nNadejda Codreanu – https://orcid.org/0009-0008-8740-0379\nKey messages\nWhat is not yet known on the issue addressed in the submit -\nted manuscript\nAssociation between clinical manifestations and the location of \ndeep endometriosis according to the #Enzian classification with \npreoperative multidisciplinary diagnosis, the impact of deep endo-\nmetriosis on pelvic pain syndrome, and the impairment of wom -\nen’s quality of life – these significant questions remain debatable.\nThe research hypothesis\nDeep endometriosis is responsible for pronounced pelvic pain syn-\ndrome, a variety of extragenital symptoms, and a significant dete -\n\n18\nMold J Health Sci. 2024;11(2):17-26Ivanova E. et al.\nrioration in the quality of women’s lives.\nThe novelty added by the manuscript to the already published scientific literature\nThe study allowed for specifying the features of the clinical course of deep endometriosis depending on the localization of its \nfoci, comparing the intensity and spectrum of the pain syndrome, as well as the impact of this pathology on the quality of life \nof women compared to patients with other forms of endometriosis.\nIntroduction \nWhile the incidence of deep infiltrating endometriosis \n(DIE) continues to rise, the pathogenesis, clinical manifes -\ntations, diagnosis, and treatment of this pathology remain \nsubjects of intensive research worldwide.\nDIE is considered the most aggressive and painful form \nof pelvic endometriosis, constituting one-fourth of its three \nphenotypes [1]. Affects 2% of women of reproductive age, \nDIE is responsible for pelvic pain syndrome, complicated \nsomatic and surgical anamnesis, and a reduced quality of \nlife for these women [2, 3]. Its diagnosis and treatment pose \nan extremely challenging task for both the global medical \ncommunity and healthcare professionals in the Republic of \nMoldova.\nAlthough DIE was first described by C. Rokitansky in \n1860, only in 2012 Koninckx proposed the first defini -\ntion of this pathology, stating that DIE is the invasion of \nendometrial tissue to a depth of more than 5 mm beneath \nthe peritoneum [4]. In 2015, the DIE lesions were discov -\nered in the intestines, bladder, ureters, and diaphragm. \nIn 2017, Balle and Dara proposed the modern definition \nof the DIE. \nThus, DIE is the pathology that involves fibromuscular \ninfiltration of the organs and anatomical structures with the \nsubperitoneal invasion of the endometrial tissues, regard -\nless of the depth of infiltration [4, 5].\nFor clinical use in 2021, the following classifications \nwere recommended: the revised American Society for Re -\nproductive Medicine (rASRM), the Endometriosis Fertility \nIndex (EFI), and the #Enzian classification. These classifica-\ntions allow staging the pathological process and assessing \nthe reproductive prognosis for each patient [6, 7].\nOf particular interest for our study is the #Enzian clas -\nsification, reflecting various locations of DIE [8]. Some \nstudies suggest that this classification correlates with the \nclinical manifestations of DIE; however, randomized studies \nare needed for definitive conclusions. From a clinical stand-\npoint, this unified reporting system simplifies the medical \nmanagement of patients, avoiding multiple repeat surgeries \nand improving the quality of treatment and quality of life for \nDIE patients [8].\nDIE most commonly affects the patients under 17 years \nold, with 20% of girls manifest the pathology simultaneous-\nly with menarche. According to the literature, the clinical \nmanifestations of DIE include the 4 “D” symptoms: dysmen-\norrhea, dyspareunia, dysuria, and dyschezia, often in com -\nbination with infertility [9]. DIE is associated with infertil -\nity, primarily due to the distortion of normal pelvic organ \nanatomy. The intensity of pelvic pain syndrome in DIE often \nexceeds 6 points on the VAS (visual analog scale), and ex -\ntragenital foci provoke the development of symptoms with \na catamenial course, such as pain during defecation, intes -\ntinal obstruction syndrome, pain during urination, hemato-\nchezia and hematuria, recurrent cystitis, chest pain, pain in \nthe operation scar with cyclic bleeding and gradual forma -\ntion increase in this area, and others [10-15].\nBased on the above information, it can be argued that \nDIE is the most aggressive and clinically vivid phenotype of \nendometriosis, significantly deteriorating the quality of life \nfor the patients [16, 17].\nInfiltration of DIE foci into adjacent organs increases \nthe frequency of interventions with surgical and anesthetic \nrisks, further diminishing the quality of women’s lives [17]. \nCurrently, evaluating the quality of life for patients is an es-\nsential element of the medical care, and studying the deter-\nminants of quality of life helps better understand the specif-\nic impact of a particular disease on the patients’ well-being \n[18]. Research reports indicate that the work productivity \nof women with DIE is reduced by 38%, 50% of patients \nsuffer from infertility, and 88% of patients experience anx -\niety disorders or depression [19]. International guidelines \nrecommend initiating studies dedicated to examining the \nquality of life of women with endometriosis using special -\nized questionnaires (SF36, EIQ, etc.) that reflect all levels of \npatients’ health [4].\nHaving reviewed the above information, it was decided \nto conduct a comparative clinical study aimed at investigat-\ning the diagnostic features of DIE and determining its im -\npact on the quality of life of patients to optimize its preop -\nerative diagnostics.\nMaterial and methods\nA single-center cohort clinical study was conducted over \n2 years at the Gheorghe Paladi Municipal Clinical Hospital. \nThe study was approved by the Research Ethics Commit -\ntee of Nicolae Testemiţanu State University of Medicine and \nPharmacy (minutes nr. 38, dated 21.05.2021). The study \nincluded reproductive-aged patients diagnosed with “En -\ndometriosis,” confirmed based on intraoperative findings or \nultrasound/MRI indications, who consented to participate \nin this study.  The exclusion criteria for this study were as \nfollows: patients under the age of majority, virgin patients, \nretired patients, patients with endometriosis malignancy, \npatients with severe extragenital pathologies (hyperten -\nsion, cardiovascular pathology, liver pathology, and others), \npatients with precancerous or cancerous conditions (cervi-\ncal, endometrial, ovarian), patients who refused to partici -\n\n19\nMold J Health Sci. 2024;11(2):17-26Deep endometriosis and quality of life\npate in the clinical study. Each patient signed an informed \nconsent form to participate in this study.\nThus, the 190 women enrolled in the study were divid -\ned into two groups: the study group comprised 85 patients \nwith deep endometriosis, while the control group consisted \nof 105 women with other forms of endometriosis (the ovar-\nian endometriomas and superficial endometriosis).\nTo objectify the pain syndrome, the Visual Analog Scale \n(VAS) and Biberoglu and Behrman (B&B) pain scales were \nused, categorizing pain as “mild,” “moderate,” “severe,” and \n“very severe.” Intraoperative data and protocol data from \nparaclinical studies were analyzed with the staging of en -\ndometrioid processes according to the #Enzian classifica -\ntion. To assess the impact of endometriosis on the quality of \nlife, three questionnaires were utilized: the Endometriosis \nImpact Questionnaire (EIQ), the 36-Item Short Form Health \nSurvey (SF-36), which identifies the impact of endometrio -\nsis on 8 determinants of quality of life, and the World Health \nOrganization-Five Well-Being Index (WHO-5), which evalu-\nates the psychological well-being of patients. Analyzed data \nwere recorded in an Excel spreadsheet, and statistical calcu-\nlations were performed using the SPSS program. For com -\nparing quantitative variables in groups, the Mann-Whitney \nU test was utilized. For comparing qualitative variables in \ngroups, the Pearson’s Chi-square test (χ²) was applied.\nResults\nGynecological anamnesis data.  Statistical comparison \ndid not reveal any age difference between the patient groups \n(U = 4520.00, p = 0.879). The average age of women in the \nmain study group was 32.39±0.81 years (95% CI [30.76 – \n34.02 years]), while in the control group, it was 30.26±0.66 \nyears (95% CI [28.91 – 31.60 years]). However, a significant \ndifference in the age of onset of menarche was found be -\ntween the study groups (U = 5697.00, p = 0.001), indicat -\ning an earlier manifestation of menstrual function among \npatients with deep infiltrating endometriosis (12.27±0.19 \nyears; 95% CI [11.89 – 12.65 years]) compared to women \nwith superficial and ovarian forms (13.18±0.20 years; 95% \nCI [12.77 – 13.59 years]). Statistical comparison of menstru-\nal cycle regularity in the research groups revealed a signifi-\ncant difference (χ² = 11.206a, df = 1, p = 0.001), indicating a \nhigher frequency of irregularities among women with deep \nendometriosis (40.0±5.4%; 95% CI [29.3 – 51.1%]) than \nthose with other phenotypes of this pathology (18.1±5.4%; \n95% CI [11.5 – 26.2%]). No statistically significant differ -\nence in menstruation duration was found between the re -\nsearch groups (U = 3840.50, p = 0.086), with a median of 5 \ndays in both groups.\nMedical history of patients. An analysis of the collected \ndata revealed that in the main study group, patients’ medi-\ncal history was uncomplicated for only 16.5±4.1% (95% CI \n[8.6 – 25.3%]), whereas in the control group, this figure was \n71.4±4.3% (95% CI [62.4 – 79.4%]), indicating a statistical-\nly significant differences (χ² = 81.844a, df = 6, p < 0.01) and \nindirectly suggesting reduced quality of life in women with \ndeep endometriosis.\nThe time to diagnosis for patients with deep endo -\nmetriosis exceeded 10 years in 67.1±5.3% (95% CI [56.5 \n– 76.7%]), while in the control group, the diagnosis was \ncorrectly made within 1 year of the disease in 56.2±4.9% \n(95% CI [46.3 – 65.6%]) of patients, indicating a statistically \nsignificant difference (χ² = 112.487 a, df = 3, p < 0.01). This \nfact indirectly confirms the reduced quality of life in women \nwith deep endometriosis.\nEndometriosis symptoms.  The results of assessing \ncomplaints from patients in this study showed the fol -\nlowing frequency of symptoms: chronic pelvic pain – \n67.89%, dysmenorrhea – 89.47%, dyspareunia – 54.74%, \ndysuria – 10.53%, dyschezia – 25.79%, menometrorrha -\ngia – 28.42%, catamenial hematuria – 4.74%, catamenial \ntenesmus of the bladder – 4.21%, hydronephrosis, uret -\neral stenting during pregnancy – 2.11%, catamenial rec -\ntal tenesmus – 22.11%, catamenial defecation disorders \n– 20.00%, catamenial intestinal subocclusion – 2.63%, \ncatamenial meteorism – 4.21%, catamenial cough and \nhemoptysis – 1.05%, catamenial breast pain and spon -\ntaneous pneumothorax – 1.05%, Benjamin’s symptom – \n50.00%, weakness – 40.00%, catamenial bleeding from \nthe scar – 2.63%, hiccups – 1.58%, frenicus symptom – \n1.58% (Fig. 1).\nPain syndrome.  Pain levels on the VAS among wom -\nen with DIE relative to the control group of patients were \ndistributed as follows: the chronic pelvic pain – 7.90±0.21 \npoints (95% CI; 7.47 – 8.34 points) vs the 2.41±0.45 \npoints (95% CI; 1.49 – 3.33 points), the dysmenorrhea \n(Dm) – 9.02±0.17 points (95% CI; 8.67 – 9.38 points) vs \nthe 5.31±0.52 points (95% CI; 4.24 – 6.37 points) (Figure \n2a), the dyspareunia (Dp) – 7.85±0.33 points (95% CI; \n7.18 – 8.53 points) vs the 2.18±0.47 points (95% CI; 1.23 \n– 3.13 points) (Figure 2b), the dysuria – 1.46±0.47 points \n(95% CI; 0.51 – 2.42 points) vs the 0 points, the dysche -\nzia – 3.83±0.56 points (95% CI; 2.70 – 4.96 points) vs the \n0 points. Statistical comparison showed significant differ -\nences between the study groups for chronic pelvic pain (U \n= 706.00, p < 0.01), dysmenorrhea (U = 1254.00, p < 0.01), \nand dyspareunia (U = 699.50, p < 0.01), while dysuria and \ndyschezia were identified as pathognomonic symptoms of \ndeep endometriosis.\nObjective pain assessment on the B&B score yielded \nthe following results among DIE patients compared to the \ncontrol group: the total symptom and sign severity score \nwas 11.39±0.364 points (95% CI; 10.65 – 12.13 points) vs \nthe 4.9±0.57 points (95% CI; 3.74 – 6.05 points) (Figure \n3), the total pelvic pain score – 7.61±0.21 points (95% CI; \n7.19 – 8.03 points) vs the 2.92±0.37 points (95% CI; 2.16 \n– 3.68 points), the total physical sign score – 3.78±0.22 \npoints (95% CI; 3.34 – 4.22 points) vs the 1.98±0.26 \npoints (95% CI; 1.46 – 2.49 points). Statistical compari -\nson of pain intensity on the B&B scale between the study \ngroups also revealed significant differences - U = 735.00, \np < 0.01, confirming a more pronounced intensity of pain \nsyndrome among women with deep infiltrating endome -\ntriosis.\n\n20\nMold J Health Sci. 2024;11(2):17-26Ivanova E. et al.\nFig. 1. Frequency of symptoms among patients in the cohort study\nFig. 2. The comparison of pain levels according to VAS dysmenorrhea Dm (a), dispareunia Dp (b) – in the research groups\n\n\n21\nMold J Health Sci. 2024;11(2):17-26Deep endometriosis and quality of life\nsions of endometriosis in compartment FA also show a \nstatistically significant correlation with menometrorrha -\ngia, catamenial rectal tenesmus, catamenial defecation \ndisorders, Benjamin’s symptom, and weakness (p < 0.05). \nLesions of endometriosis in compartment FB, as per the \n#Enzian classification, demonstrate a statistically signifi -\ncant association with chronic pelvic pain, dysmenorrhea \nand dysuria > 7 points after VAS, catamenial hematuria, \ncatamenial bladder tenesmus, hydronephrosis with uret -\neral stenting during pregnancy, Benjamin’s symptom, and \nweakness (p < 0.05). Statistically significant correlations \nexist between lesions of endometriosis in compartment FI, \ncategorized by the #Enzian classification, and catamenial \ndefecation disorders, catamenial intestinal subocclusion, \ncatamenial meteorism, Benjamin’s symptom, weakness (p \n< 0.05). As per the #Enzian classification, lesions of endo -\nmetriosis in compartment FO exhibit statistically signifi -\ncant correlations with chronic pelvic pain, dysmenorrhea, \ndyspareunia > 7 points after VAS, catamenial cough, he -\nmoptysis, catamenial chest pain and spontaneous pneu -\nmothorax, catamenial hemorrhagic scar, hiccups, phrenic \nsign (p < 0.05).\nTable 1 displays the frequency distribution of statisti -\ncally significant symptoms depending on the localization of \ndeep endometriosis, corresponding to the compartments of \nthe #Enzian classification.\nQuality of life in endometriosis.  According to the re -\nsults of the EIQ questionnaire calculation, deep endome -\ntriosis significantly affected the majority of life determi -\nnants in patients compared to the control group of wom -\nen, negatively influencing the quality of life. The physical \nhealth of the main research group’s patients was reduced \nby 64.49±3.39% (95% CI; 57.63 – 71.34%), whereas in the \ncontrol group it was reduced by 14.13±2.40% (95% CI; \n9.26 – 18.99%). The main research group’s patients expe -\nrienced a 70.27±3.06% (95% CI; 64.08 – 76.46%) reduc -\ntion in mental health compared to a 14.10±2.71% (95% CI; \n8.61 – 19.60%) reduction in the control group. The social \nfunction of the main research group’s patients was reduced \nby 52.68±4.38% (95% CI; 43.81 – 61.55%), whereas in the \ncontrol group it was reduced by 4.72±1.82% (95% CI; 1.03 \n– 8.40%). In comparison to the control group, the patients \nin the main research group showed a 64.9±4.53% (95% \nCI; 55.74 – 74.07%) decrease in sexual function, while the \ncontrol group experienced a 12.74±2.97% (95% CI; 6.76 – \n18.73%) decrease. The fertility of patients in the main re -\nsearch group deteriorated by 90.93±3.54% (95% CI; 83.77 \n– 98.09%), in contrast to a 79.90±5.45% (95% CI; 68.86 – \n90.93%) deterioration observed in the control group. The \nmain research group’s patients experienced a 58.76±4.58% \n(95% CI; 49.50 – 68.02%) reduction in work capacity com -\npared to a 4.77±1.52% (95% CI; 1.68 – 7.86%) reduction \nin the control group. Relative to the control group, patients \nfrom the main research group exhibited a 44.27±4.12% \n(95% CI; 35.95 – 52.59%) decrease in educational atten -\ndance, whereas the control group demonstrated a reduc -\ntion of only 3.64±1.33% (95% CI; 0.95 – 6.33%). The life -\nFig. 3. Comparison of the pain level according to B&B scale \nin the research groups.\nLocalization of deep endometriosis according to the \n#Enzian classification. Analysis of the localization of deep \nendometriosis foci in the main research group showed \nthe following frequency distribution of this pathology by \ncompartments of the #Enzian classification: localization \nin compartment A (the rectovaginal septum and vagina) – \n55.3±5.3% (95% CI [45.2 – 65.5%]); in compartment B (the \nuterosacral ligament and pelvic walls) – 8.2±2.9% (95% CI \n[3.4 – 14.4%]); in compartment C (the sigmoid colon and \nrectum) – 1.2±1.2% (95% CI [0.0 – 3.8%]); in compartment \nFA (adenomyosis) – 17.6±4.2% (95% CI [10.0 – 26.3%]); in \ncompartment FВ (the bladder) – 17.6±3.9% (95% CI [10.0 \n– 25.3%]); in compartment FI (the intestine) – 9.4±3.2% \n(95% CI [3.7 – 16.2%]); in compartment FO (other loca -\ntions) – 12.9±3.7% (95% CI [6.0 – 20.5%]).\nCorrelation between #Enzian compartments and \nsymptoms. Lesions of DIE in compartments A, B, FA, FI \naccording to #Enzian classification statistically correlat -\ned with chronic pelvic pain, dysmenorrhea, dyspareunia \nand dyschezia > 7 points after VAS (p < 0.05). Additional -\nly, lesions of DIE in compartment A according to #Enzian \nclassification statistically correlated with catamenial rec -\ntal tenesmus, catamenial defecation disorders, Benjamin’s \nsymptom, and weakness (p < 0.05). At the same time, le -\nsions of deep endometriosis in compartment B according \nto the #Enzian classification are statistically correlated \nwith catamenial rectal tenesmus. The patient with a focus \nof deep endometriosis in compartment C according to the \n#Enzian classification presented with the following symp -\ntoms: chronic pelvic pain, dysmenorrhea, dyspareunia, and \ndyschezia > 7 points after VAS, catamenial rectal tenesmus, \ncatamenial defecation disorders, Benjamin’s symptom, \nand weakness. However, due to only one case, it would \nbe inappropriate to discuss the statistical significance of \nthese results. According to the #Enzian classification, le -\n\n22\nMold J Health Sci. 2024;11(2):17-26Ivanova E. et al.\nAccording to the SF-36 questionnaire calculation results, \ndeep endometriosis significantly affected the quality of life \nof patients, as evidenced by the reduction in the realization \nof life determinants in women with deep endometriosis \ncompared to similar data in the control group.\nThus, the realization of the general health potential \n(GH) among women in the main research group amount -\ned to 42.15±3.42% (95% CI; 35.23 – 49.06%), compared \nto 76.23±3.02% (95% CI; 70.12 – 82.34%) in the research \ncontrol group. The realization of the ability to perform \nTable 1. Statistically verified correlation between #Enzian compartments and symptoms (p < 0.05).\nA B FA FB FI FO\nChronic pelvic pain > 7 VAS 85.1% 100% 100% 86.7% 87.5% 90.9%\nDysmenorrhea > 7 VAS 97.8% 100% 100% 93.3% 100% 90.9%\nDyspareunia > 7 VAS 93.6% 100% 86.7% - 75.0% 45.4%\nDysuria > 7 VAS - - - 86.7% - -\nDyschesia > 7 VAS 53.2% 42.8% 46.7% - 87.5% -\nMenometrorrhagia - - 100% - - -\nHematuria - - - 60.0% - -\nTenesmus vesical - - - 100% - -\nHydronephrosis, ureteral stenting - - - 26.7% - -\nTenesmus rectal 57.4% 71.4% 73.3% - - -\nDefecation disorders 57.5% - 60.0% - 100% -\nIntestinal suboccluzion - - - - 62.5% -\nMeteorism - - - - 87.5% -\nCough, hemoptysis - - - - - 18.2%\nChest pain - - - - - 18.2%\nSymptom Benjamin 85.1% - 80.0% 93.3% 100% -\nWeakness 74.5% - 80.0% 73.3% 87.5% -\nHemorrhagic scar - - - - - 45.5%\nHiccups - - - - - 27.3%\nPhrenic sign - - - - - 27.3%\nNote: A – DIE in the rectovaginal septum and vagina; B – DIE in the uterosacral ligament and pelvic walls; FA - adenomyosis; FB – DIE in the bladder; FI – DIE in \nthe intestine; FO – DIE in other locations\nFig. 4 Comparison of the general health (GH) by SF-36 Fig. 5 Comparison of the physical functioning (PF) by SF-36 \nstyle of patients in the main research group deteriorated \nby 53.02±5.54% (95% CI; 41.83 – 64.22%) in contrast to \na 2.28±1.24% (95% CI; -0.22 – 4.79%) deterioration ob -\nserved in the control group. Comparison of EIQ question -\nnaire results revealed a statistically significant difference in \nthe impact of pathologies in the research groups on physical \nhealth (U = 479.00, p < 0.01) and mental health of patients \n(U = 311.00, p < 0.01), on social function (U = 701.50, p < \n0.01), sexual function (U = 690.50, p < 0.01), fertility (U = \n1107.50, p = 0.001), work capacity (U = 841.00, p < 0.01), \nattendance of education (U = 567.50, p < 0.01), and lifestyle \n(U = 850.00, p < 0.01).\n\n23\nMold J Health Sci. 2024;11(2):17-26Deep endometriosis and quality of life\nFig. 6 Comparison of the role-physical health (RP)\nby SF-36 \nFig. 7 Comparison of the role-emotional (RE)\nby SF-36 \nFig. 8 Comparison of the bodily pain (BP) by SF-36 Fig. 9 Comparison of the vitality (VT) by SF-36\nusual physical activities (PF) among women in the main \nresearch group amounted to 58.54±4.11% (95% CI; 50.22 \n– 66.85%), compared to 92.18±1.95% (95% CI; 88.23 – \n96.13%) in the research control group. The realization of \nperformance of work or other duties (RP) among women \nin the main research group was 39.63±5.16% (95% CI; \n29.20 – 50.07%), as opposed to 89.10±3.41% (95% CI; \n82.20 – 96.01%) in the research control group. The perfor -\nmance of work or other duties in the context of emotion -\nal limitations, denoted as RE, among women in the main \nresearch group was measured at 37.78±4.54% (95% CI; \n28.60 – 46.96%), contrasting with 85.59±3.99% (95% CI; \n77.50 – 93.68%) in the research control group. The level of \nsocial activity and impact of physical or emotional health \non social life (SF), among women in the main research \ngroup was measured at 47.12±1.02% (95% CI; 45.05 – \n49.20%), contrasting with 51.41±1.01% (95% CI; 49.35 – \n53.47%) in the research control group. Among women in \nthe main research group, the degree of physical activity in -\nfluenced by pain, referred to as BP , averaged 28.32±3.35% \n(95% CI; 21.53 – 35.11%), in contrast to 77.46±4.34% \n(95% CI; 68.67 – 86.25%) in the research control group. \nThe energy and vitality, designated as VT , among women in \nthe primary research cohort, averaged 42.44±2.80% (95% \nCI; 36.78 – 48.10%), compared to 76.26±3.30% (95% CI; \n69.56 – 82.95%) in the control cohort. Women in the main \nresearch group demonstrated mental well-being and men -\ntal health, termed as MH, of 47.32±2.37% (95% CI; 42.51 \n– 52.12%), while those in the control group exhibited a \nlevel of 77.23±2.96% (95% CI; 71.23 – 83.23%) for men -\ntal well-being. The statistically significant difference in the \nresearch groups was confirmed in GH (U = 8045.50, p < \n\n24\nMold J Health Sci. 2024;11(2):17-26Ivanova E. et al.\n0.01, Figure 4), PF (U = 8037.50, p < 0.01, Figure 5), RP (U \n= 7852.50, p < 0.01, Figure 6), RE (U = 7715.00, p < 0.01, \nFigure 7), BP (U = 7997.000, p < 0.01, Figure 8), VT (U = \n7911.00, p < 0.01, Figure 9), MH (U = 7991.50, p < 0.01, \nFigure 10). And only for the level of SF, a statistically sig -\nnificant difference was not determined (U = 4689.00, p = \n0.473, Figure 11).\nAccording to the WHO-5 Well-Being Index question -\nnaire, the level of psychological well-being in patients \nwith deep endometriosis compared to the control group \nof women was 44.29±2.05% (95% CI; 40.15 – 48.44%) vs. \n81.38±2.72% (95% CI; 75.88 – 86.89%). Despite the fact \nthat the average level of psychological well-being did not \nreach 100% for all women included in this study, in the \ngroup of patients with deep infiltrating endometriosis, this \nparameter was significantly lower, as confirmed by a statis-\ntically significant difference in psychological well-being in \nthe research groups - U = 8277.00, p < 0.01 (Figure 12).\nDiscussion\nThe results of our study offer valuable insights into the \nclinical and psychological characteristics of women with \ndifferent phenotypes of endometriosis. Based on the data \nobtained, several key aspects can be highlighted.\nFirstly, women suffering from deep infiltrating endo -\nmetriosis (DIE) not only experience more intense pain, but \nalso a wider spectrum of symptoms compared to patients \nwith other phenotypes of this condition. This finding un -\nderscores the importance of early detection and accurate \ndiagnosis of DIE to ensure timely treatment and improve \nthe quality of life of patients. Secondly, our data indicate \na high risk of recurrent surgical intervention in women \nwith DIE, as this condition often may masquerade as ex -\ntragenital pathologies. This highlights the importance of \nconducting more comprehensive clinical and paraclinical \nFig. 10 Comparison of the mental health (MH) \nby SF-36\nFig. 11 Comparison of the social functioning (SF)\nby SF-36\nFig. 12 Comparison of psychological well-being in \nresearch groups according to the WHO-5 Index.\nexaminations when suspecting DIE to distinguish it from \nother nosological entities. Thirdly, our results confirm that \nsevere pelvic pain syndrome is a characteristic feature of \nDIE and can be considered an important diagnostic indi -\ncator of this pathology. This emphasizes the need for an \nintegrated approach to assessing pelvic pain syndrome \nin women suspected of having DIE. Fourthly, the results \nof our study, consistent with data from some internation -\nal colleagues, have identified an association between the \nlocalization of DIE according to the #Enzian classification \nand clinical symptoms, which is an important aspect in the \npreoperative diagnostic process. These findings, together \nwith existing literature, support recommending the #En -\n\n25\nMold J Health Sci. 2024;11(2):17-26Deep endometriosis and quality of life\nzian classification as the primary method for staging and \nmapping foci of DIE for surgical treatment by a multidisci -\nplinary team. Finally, our results allow us to better under -\nstand the impact of DIE on the quality of life of patients. \nPatients with this type of endometriosis have a lower level \nof quality of life and psychological well-being compared to \nother phenotypes of endometriosis. This underscores the \nneed for developing individualized treatment and support \napproaches for patients with DIE.\nOverall, our results have important clinical and practical \nimplications and can serve as a basis for further research \nand improvement of approaches to the diagnosis, treat -\nment, and support of patients with DIE.\nHowever, it is important to acknowledge the limitations \nof our study. Firstly, despite being prospective, our sample \nsize was relatively small, which may limit the generalizabil-\nity of our findings. Secondly, the prospective nature of the \nstudy does not preclude the possibility of selection bias \nand reliance on medical records for data collection. Future \nstudies with larger sample sizes and more comprehensive \ndata collection methods are needed to further validate our \nresults and address these limitations.\nConclusions \nHigh-intensity pain syndrome and extragenital symp -\ntoms correlated with compartments of #Enzian will assist \nin the preoperative multidisciplinary diagnosis of DIE. The \nhigh influence on life determinants, the low realization of \nlife potential, and the low psychological well-being confirm \nthe significant impact of DIE on QoL, suggesting its classifi -\ncation as a disability.\nCompeting interests \nNone declared.\nAuthors’ contributions\nEI conceived the study and participated in the study \ndesign, contacted and included subjects in research, an -\nalyzed and calculated information from questionnaires, \nperformed the statistical analysis of collected data, draft -\ned the manuscript, reviewed the work critically, and ap -\nproved the final version of the manuscript. NC proposed \nthe study’s area, conceived the study design, controlled \nmain points of its realization, and reviewed the work crit -\nically. Both authors have read and approved the final ver -\nsion of the manuscript.\nAcknowledgements and funding\nWe express our gratitude to Gheorghe Paladi, a profes -\nsor and academician, who advised us to pursue research in \nthe gynecological field and supported the realization of this \nstudy. The study had no external funding.\nPatient consent \nObtained.\nEthics approval\nThe study protocol was approved by the Research Ethics \nCommittee of Nicolae Testemiţanu State University of Medi-\ncine and Pharmacy (minutes No. 38, from 21.05.2021).\nReferences\n1. Donnez O. Conservative management of rectovaginal deep \nendometriosis: shaving should be considered as the prima-\nry surgical approach in a high majority of cases. J Clin Med. \n2021 Nov 5;10(21):5183. doi: 10.3390/jcm10215183. \n2. Imperiale L, Nisolle M, Noël JC, Fastrez M. 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