Quality of life improves after endometriosis surgery independent of #ENZIAN classification: a multicenter cohort study

Background Endometriosis is a chronic inflammatory disease associated with substantial impairment of quality of life. Although the #ENZIAN classification enables detailed anatomical characterization of disease distribution, its relevance for predicting patient-reported outcomes after surgery remains uncertain. Clarifying this relationship is essential for patient counseling and outcome-oriented surgical decision making.

This multicenter study, registered on ClinicalTrials.gov (NCT05624567), prospectively recruited consecutive women aged 18 to 50 years undergoing surgery for suspected endometriosis at certified endometriosis centers in Austria, Germany, and Switzerland. Only women with surgically and histopathologically confirmed endometriosis who completed the baseline Endometriosis Health Profile-30 (EHP-30) questionnaire were included in the final analysis. Disease localization was classified intraoperatively using the #ENZIAN and rASRM systems. Quality of life was assessed using the EHP-30 questionnaire preoperatively and at 6 and 12 months after surgery. Longitudinal changes and predictors of quality-of-life outcomes were analyzed using ordinal logistic regression models.

A total of 627 women were included at baseline, with 430 and 325 completing 6- and 12-month follow-up, respectively. Surgical treatment was associated with a marked and clinically meaningful improvement in quality of life, with EHP-30 scores improving significantly within the first 6 months after surgery and remaining stable at 12 months. This improvement was observed consistently across all #ENZIAN compartments, including deep infiltrating and multifocal disease. Anatomical disease distribution and rASRM stage were not significantly associated with baseline quality-of-life or postoperative recovery trajectories. In contrast, baseline symptom burden and complete surgical resection emerged as the strongest predictors of early postoperative quality-of-life improvement.

Surgical treatment of endometriosis was associated with substantial and sustained improvement in patient-reported quality of life, independent of anatomical disease distribution as classified by #ENZIAN. These findings suggest that meaningful postoperative benefit can be achieved across all disease localizations and underscore the importance of focusing on symptom severity and surgical completeness rather than anatomical staging alone. Incorporating patient-reported outcome measures alongside anatomical classification is essential for comprehensive evaluation of treatment success. Abbreviations - A: - Adenomyosis compartment (according to #ENZIAN classification) - B: - Rectovaginal septum and uterosacral ligaments compartment (according to #ENZIAN classification) - BMI: - Body mass index - CI: - Confidence interval - DIE: - Deep infiltrating endometriosis - EEL: - European Endometriosis League - EFI: - Endometriosis Fertility Index - EHP: - 30–Endometriosis Health Profile–30 - FA: - Adenomyosis of the uterus, subtype A (according to #ENZIAN classification) - FB: - Bladder involvement (according to #ENZIAN classification) - FU: - Ureter involvement (according to #ENZIAN classification) - FUP: - Follow–up - IQR: - Interquartile range - MRI: - Magnetic resonance imaging - O: - Ovarian endometriosis compartment (according to #ENZIAN classification) - P: - Peritoneal endometriosis compartment (according to #ENZIAN classification) - QoL: - Quality of life - rASRM: - Revised American Society for Reproductive Medicine (classification) - SEF: - Stiftung Endometriose Forschung - T: - Tubo–ovarian compartment (according to #ENZIAN classification)

The authors thank all participating patients and the clinical staff at the contributing endometriosis centers for their support of this study. Funding This study received no external funding. Author information Authors and Affiliations Corresponding author Ethics declarations Ethics approval and consent to participate The study protocol was approved by the Ethics Committee of the Medical University of Vienna (EK 1629/2022). Additional approval was obtained from the Ethics Committee of the Medical University of Innsbruck (1131/2022), the Ethics Committee of the Medical University of Graz (35–065 ex 22/23), the Ethics Committee of the City of Vienna (EK 22-244-VK), the Ethics Committee of the Medical Faculty of Johannes Kepler University Linz (1175/2022), the Ethics Committee of Carinthia (M2022-56), the Ethics Committee at LMU Munich (22–0842), the Ethics Committee of the Medical Faculty of Eberhard Karls University and University Hospital Tübingen (511/2022BO2), the Ethics Committee of the Hamburg Medical Association (2023-200712-BO-bet), the Ethics Committee at TU Dresden (BO-EK-458102022), the Cantonal Ethics Committee of Zurich (2022–02294), the Ethics Committee of the Baden-Württemberg State Medical Association (F-2023-017), and the Ethics Committee of the Technical University of Munich (2023-407-S-NP). Approval was also obtained from the Ethics Committee of the Hospital of the Brothers of St. John of God, Vienna, for which no reference number was assigned. For St. Elisabeth Hospital Damme, the Lower Saxony Ethics Committee (Ethikkommission bei der Ärztekammer Niedersachsen) confirmed that no additional local ethics approval was required and accepted the ethics approvals already obtained for the multicenter study. Written informed consent was obtained from all participants before study inclusion. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Additional information Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Supplementary Information Below is the link to the electronic supplementary material. Rights and permissions Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. About this article Cite this article Perricos-Hess, A., Gstoettner, M., Heinzl, F. et al. Quality of life improves after endometriosis surgery independent of #ENZIAN classification: a multicenter cohort study. BMC Med (2026). https://doi.org/10.1186/s12916-026-05136-9 Received: Accepted: Published: DOI: https://doi.org/10.1186/s12916-026-05136-9