{"paper_id":"598be1fe-252a-44e5-af33-96b906c37dc6","body_text":"Arch Obstet Gynecol. 2025\nVolume 6, Issue 2\nArchives of Obstetrics and Gynaecology Editorial\n82\nArch Obstet Gynecol. 2025;6(2):82–84.\nComprehensive Management of Endometriosis: Implementation \nfrom Research to Clinical Practice\nElliot M. Levine1,*, Carlos M. Fernandez3, Teresa Tam2\n1Rosalind Franklin University Chicago Medical School North Chicago, Illinois, USA\n2Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA\n3Ascension Saint Joseph Hospital, Chicago, Illinois, USA\n*Correspondence should be addressed to Elliot M. Levine, Elliot.Levine@rosalindfranklin.edu\nReceived date: September 29, 2025, Accepted date: October 01, 2025\nCitation: Levine EM, Fernandez CM, Tam T. Comprehensive Management of Endometriosis: Implementation from Research to \nClinical Practice. Arch Obstet Gynecol. 2025;6(2):82–84.\nCopyright: © 2025 Levine EM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution \nLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are \ncredited.\nEditorial\nEndometriosis is a chronic inflammatory condition that \noccurs when endometrial-like tissue grows outside the uterus, \ncommonly leading to symptoms such as dysmenorrhea and \nchronic pelvic pain (CPP) [1]. While diagnosis and treatment \nfocus on pelvic reproductive organs, research shows that \nthe appendix can also be involved in endometriosis patients \nand may contribute to symptom burden. This potential \nsite of disease is commonly overlooked in clinical practice \nsince routine appendiceal evaluation is not part of standard \nsurgical protocols for endometriosis. Current clinical \nguidelines, including those established by the American \nCollege of Obstetricians and Gynecologists (ACOG), do not \nrequire appendiceal examination during surgical exploration \nfor endometriosis, potentially leaving a treatable source of \nsymptoms undetected [2,3]. \nResearch shows that appendiceal endometriosis (AE) is \nmore common than once thought, with infiltrative disease  \noften present despite a normal-appearing appendiceal \nsurface [4–7]. While surgeons routinely visually assess pelvic \norgans to identify superficial peritoneal implants and ovarian \nendometriomas during diagnostic laparoscopy, the appendix, \nwhether in its typical anatomical position or retrocecally \nlocated, can be easily accessed and examined through both \nlaparoscopic and open surgical approaches. Studies show \nthat prophylactic appendectomy in patients undergoing \nendometriosis surgery provides both confirmatory \nhistopathological diagnosis and symptom improvement with \nminimal additional morbidity [8].\nSince the appendix is accessible during both laparoscopic \nand open endometriosis procedures, systematic appendiceal \nevaluation and prophylactic appendectomy represent an \nimportant consideration in comprehensive endometriosis \nmanagement. This approach improves diagnostic accuracy, \neliminates a frequently overlooked source of persistent \nsymptoms, and leads to better long-term surgical outcomes \nfor patients with endometriosis. Treating AE during the initial \nAbstract\nAppendiceal endometriosis (AE) represents a clinically significant yet frequently overlooked manifestation of endometriosis that may contribute \nto persistent symptoms and suboptimal treatment outcomes. Multiple comprehensive reviews demonstrate that appendiceal involvement \noccurs in a notable percentage of women with endometriosis and can present with distinctive symptom patterns. Despite this growing \nbody of evidence, routine appendiceal evaluation during surgical exploration for endometriosis remains inconsistently implemented across \nsurgical practices. The failure to identify and treat AE may result in continued symptomatology despite otherwise successful endometriosis \nsurgery, potentially necessitating additional interventions and compromising patient quality of life.\nKeywords: Endometriosis, Appendicitis, Appendiceal endometriosis, Dysmenorrhea, Primary dysmenorrhea, Implementation, Chronic \npelvic pain\n\nLevine EM, Fernandez CM, Tam T. Comprehensive Management of Endometriosis: Implementation from Research to \nClinical Practice. Arch Obstet Gynecol. 2025;6(2):82–84.\nArch Obstet Gynecol. 2025\nVolume 6, Issue 2\n83\nsurgery may reduce the need for subsequent interventions \nand improve overall patient satisfaction by providing better \nsymptom relief [9].\nReview of Current Data Regarding Endometriosis and \nthe Appendix\nAn investigation involving the sonographic identification \nof deep infiltrating endometriosis (DIE) also identified cases \nof AE. In this study, gynecologic physicians collaborated to \nverify the presence of DIE through sonographic, surgical, and \nhistological assessments [10]. AE was coincidentally identified \nin five of the seven cases (71%) in which appendectomy was \nperformed (total of 5% of the 100 cases of DIE examined), with \nendometriotic implants affecting the appendix in five cases, \nthough ultrasound did not detect AE in any of those cases \npreoperatively. Histologic evidence of endometriosis depends \non finding at least two of the three associated elements (i.e. \nendometrial glands, stroma, and hemosiderin deposits) [11]. In \neach AE case from this series, all three elements were present \nbut none of the operative reports indicated any specific signs \nof appendicitis. \nMultiple studies across diverse patient populations have \ndocumented significant rates of AE. Ross and colleagues \nexamined 609 women with CPP who underwent \nappendectomy and found histopathologic evidence of AE in \n14.9% of cases [4]. Similarly, Nikou et al. studied 135 patients \nwith clinically diagnosed endometriosis who had concurrent \nappendectomy, revealing AE in 25% of cases despite the \nabsence of consistent preoperative indicators [5]. Guo et al. \nreported that among 108 patients with Stage IV endometriosis, \n35.8% of those who had an appendectomy had evidence of AE \n[6]. Centini et al. found a lower prevalence of 2.8% among 486 \npatients undergoing surgery for presumptive endometriosis \n[7]. Collectively, these studies demonstrate that AE occurs \nin 2.8% to 35.8% of cases, with prevalence rates varying \naccording to patient selection criteria and disease severity. \nAdditionally, Schrempf et al.  evaluated 2,484 patients \nadmitted for acute appendicitis without known endometriosis \nhistory and identified histologic evidence of AE in 0.7% of \ncases, suggesting that AE may occur even in the absence \nof recognized pelvic endometriosis [12].  This finding is \nsupported by multiple case reports demonstrating that AE \ncan present with acute symptomatology that closely mimics \nclassic appendicitis, potentially leading to misdiagnosis [13–\n15]. Importantly, Ross and colleagues emphasized that the \ndetection rate of AE is significantly influenced by the rigor and \nmethodology of histopathologic examination, suggesting \nthat AE may be underdiagnosed when standard pathologic \nprotocols are employed [16]. A comprehensive review and \nanalysis of AE was provided by Mabrouk et al.  [17] and by \nAllahqoli et al. [18], further highlighting the clinical relevance \nof AE.\nSurgical intervention for endometriosis occurs either for \ndiagnostic confirmation when the diagnosis is uncertain \nor medical therapy has failed, or for definitive treatment of \nestablished disease. In diagnostic cases, histologic sampling \nof suspicious implants or deep infiltrating endometriosis \nis required, while therapeutic cases necessitate complete \nremoval of all endometriotic tissue. Current evidence strongly \nsupports concurrent appendectomy in both scenarios, as \nAE frequently lacks visual manifestations and can only be \nconfirmed histologically. Multiple studies demonstrate \nthat prophylactic appendectomy adds minimal morbidity \nduring endometriosis surgery [5,6,18], with several authors \nadvocating for this approach in all cases of suspected or \nconfirmed endometriosis [7,15,16]. \nEndometriosis significantly impacts patients through \ndysmenorrhea, chronic pelvic pain, and infertility, yet diagnosis \nis frequently delayed by 5–12 years, contributing to patient \ndissatisfaction and physician mistrust [19–23]. Misdiagnosis or \nunder-recognition of endometriosis’ various manifestations, \nincluding peritoneal, ovarian, and deep infiltrating disease, \nprolongs patient suffering and delays appropriate treatment. \nComprehensive interdisciplinary management is essential [24] \nand should include recognition of frequently overlooked AE.\nClinical Implications of Collected Data\nRecognizing and diagnosing AE is essential for ensuring that \npatients receive appropriate medical and/or surgical treatment \nto effectively alleviate associated symptoms. Criticism of \nthe less-than-ideal transferring of research findings toward \nstandard clinical practice has been previously offered, and \nthe slowness of adoption of this comprehensive management \nof endometriosis may be a modern example of this failed \nimplementation. A thorough analysis of other past scientific \nimplementation problems was presented by Dr. Evans [25], \nwhich may be relevant to this clinical review. The delay in \ntranslating compelling scientific data into standard care \nprotocols may perpetuate suboptimal treatment outcomes \nfor patients with endometriosis. \nConflicts of Interest \nThe authors deny any conflicts of interest.\nFunding \nThere was no funding for this investigation.\nReferences\n1. Olive DL, Schwartz LB. Endometriosis. N Engl J Med. 1993 Jun \n17;328(24):1759–69.\n2. Practice bulletin no. 114: management of endometriosis. Obstet \nGynecol. 2010 Jul;116(1):223–36.\n\nLevine EM, Fernandez CM, Tam T. Comprehensive Management of Endometriosis: Implementation from Research to \nClinical Practice. Arch Obstet Gynecol. 2025;6(2):82–84.\nArch Obstet Gynecol. 2025\nVolume 6, Issue 2\n84\n3. Chronic pelvic pain. Practice Bulletin, No. 218. American \nCollege of Obstetricians and Gynecologists. Obstet Gynecol \n2018;135(3):e98-e109.\n4. Ross WT, Chu A, Li L, Kunselman AR, Harkins GJ, Deimling TA, \net al. Appendectomy in the surgical management of women \nwith endometriosis and pelvic pain. Int J Gynaecol Obstet. 2021 \nSep;154(3):526–31.\n5. Nikou AF, Tenzel NS, Hua P , Orbuch L, Orbuch IK. Appendectomy \nShould Be Performed During Minimally Invasive Surgery for \nEndometriosis. JSLS. 2021 Jan-Mar;25(1):e2020.00095.\n6. Guo C, Chen MZ, Chiu T, Condous G, Barto W. The appendix in \nendometriosis. Aust N Z J Obstet Gynaecol. 2023 Dec;63(6):792–6.\n7. Centini G, Ginetti A, Colombi I, Cannoni A, Giorgi M, Ferreira H, et \nal. Endometriosis of the appendix: prevalence, associated lesions, \nand proposal of pathogenetic hypotheses. A retrospective cohort \nstudy with prospectively collected data. Arch Gynecol Obstet. \n2024 Sep;310(3):1669–75.\n8. Galaviz VD, Nguyen AD, Sticco PL, Downing KT. Appendectomy \nin endometriosis: an update on surgical indications and \nmanagement of uncommon diseases. Curr Opin Obstet Gynecol. \n2023 Aug 1;35(4):377–82.\n9. Tam T, Harkins G. Elective laparoscopic appendectomy in \ngynecologic surgery: When, why, and how. Contemp Obstet \nGynecol 2013;25(3):42–9.\n10. Fernandez CM, Levine EM, Shashoua A, Tam MT, Diaz L. The \nexpanding role of sonography for the diagnosis of deep \ninfiltrating endometriosis: Results of a large case series. Int J \nGynaecol Obstet. 2024 Jul;166(1):326–32.\n11. Camboni A, Marbaix E. Ectopic Endometrium: The Pathologist's \nPerspective. Int J Mol Sci. 2021 Oct 11;22(20):10974.\n12. Schrempf M, Kirmair MA, Mair A, Hoffmann M, Dannecker C, \nAnthuber M, et al. Incidence and clinical features of endometriosis \nin 2484 consecutive female patients undergoing appendectomy \nfor suspected appendicitis-a retrospective analysis. Langenbecks \nArch Surg. 2024 Apr 29;409(1):144.\n13. Laskou S, Papavramidis TS, Cheva A, Michalopoulos N, Koulouris \nC, Kesisoglou I, et al. Acute appendicitis caused by endometriosis: \na case report. J Med Case Rep. 2011 Apr 11;5:144.\n14. Al Oulaqi NS, Hefny AF, Joshi S, Salim K, Abu-Zidan FM. \nEndometriosis of the appendix. Afr Health Sci. 2008 Sep;8(3):196–\n8.\n15. St John BP , Snider AE, Kellermier H, Minhas S, Nottingham JM. \nEndometriosis of the appendix presenting as acute appendicitis \nwith unusual appearance. Int J Surg Case Rep. 2018;53:211–3.\n16. Ross WT, Newell JM, Zaino R, Kunselman AR, Harkins GJ, Benton \nAS. Appendiceal Endometriosis: Is Diagnosis Dependent on \nPathology Evaluation? A Prospective Cohort Study. J Minim \nInvasive Gynecol. 2020 Nov-Dec;27(7):1531–7.\n17. Mabrouk M, Raimondo D, Mastronardi M, Raimondo I, Del Forno S, \nArena A, et al. Endometriosis of the Appendix: When to Predict and \nHow to Manage-A Multivariate Analysis of 1935 Endometriosis \nCases. J Minim Invasive Gynecol. 2020 Jan;27(1):100–6.\n18. Allahqoli L, Mazidimoradi A, Momenimovahed Z, Günther V, \nAckermann J, Salehiniya H, et al. Appendiceal Endometriosis: A \nComprehensive Review of the Literature. Diagnostics (Basel). \n2023 May 23;13(11):1827.\n19. Taylor HS, Kotlyar AM, Flores VA. Endometriosis is a chronic \nsystemic disease: clinical challenges and novel innovations. \nLancet. 2021 Feb 27;397(10276):839–52.\n20. Bontempo AC, Mikesell L. Patient perceptions of misdiagnosis of \nendometriosis: results from an online national survey. Diagnosis \n(Berl). 2020 May 26;7(2):97–106.\n21. Requadt E, Nahlik AJ, Jacobsen A, Ross WT. Patient experiences \nof endometriosis diagnosis: A mixed methods approach. BJOG. \n2024 Jun;131(7):941–51.\n22. Zondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl J \nMed. 2020 Mar 26;382(13):1244–56.\n23. As-Sanie S, Mackenzie SC, Morrison L, Schrepf A, Zondervan \nKT, Horne AW, et al. Endometriosis: A Review. JAMA. 2025 Jul \n1;334(1):64–78.\n24. Carey ET, Wong JMK, Khan Z. Comprehensive Review of \nEndometriosis Care. Obstet Gynecol. 2025 Jul 17;146(3):323–40.\n25. Evans MI, Britt DW. Resistance to Change. Reprod Sci. 2023 \nMar;30(3):835–53.","source_license":"CC0","license_restricted":false}