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. 2025 Mar 31:26:100386.
doi: 10.1016/j.eurox.2025.100386. eCollection 2025 Jun.

Extragenital endometriosis associated with uterine scar defects

Tilman Born  1 , Katrin Krejci  1 , Maximilian Rauh  1 , Georgia Cole  1 , Maurice Kappelmeyer  1 , Mehmet Vural  1 , Angela Köninger  1
Affiliations

Extragenital endometriosis associated with uterine scar defects

Tilman Born et al. Eur J Obstet Gynecol Reprod Biol X. .

Abstract

Introduction: Uterine scar defects result from poor healing of the hysterotomy after cesarean sections (CS), in multiple cases leading to retroflexio uteri and retrograde menstruation. Endometriosis is the probable consequence. Patients often experience overlapping symptoms such as dysmenorrhea, dyspareunia, and infertility.

Material and methods: This study analysed cases of sonographically detected uterine scar defects, subsequently undergoing laparoscopy at the University Clinic St. Hedwig, in Regensburg, between 2020 and 2024. Herefore, surgery reports were reviewed, focusing on extragenital endometriosis, symptoms of Cesarean Scar Disorder (CSD), niche morphology, uterine position, and endometriosis localisation using the #Enzian classification.

Results: Extragenital endometriosis was histologically confirmed in 45 of 94 patients (47.9 %) with symptomatic or large uterine niches. A significant association was found between endometriosis and heavy menstrual bleeding (HMB) (p < 0.001) as well as retroflexio uteri (p = 0.036). Symptoms related to CSD did not differ in patients with or without Endometriosis. Endometriotic implants were primarily located in the peritoneum behind the uterus and sacrouterine ligaments, supporting the hypothesis of retrograde menstruation.

Conclusion: There is significant overlap between the symptoms of endometriosis and CSD. Almost half of the patients with a symptomatic niche were found to have endometriosis, whereby the location of endometriosis supports the hypothesis of retrograde menstruation. However, the patient´s history of complaints is not indicative of the diagnosis of endometriosis. Therefore, all patients with CSD should be offered a laparoscopy and endometriosis surgery. All patients with a previous caesarean section presenting with symptoms of endometriosis should be offered standardised and high-quality niche diagnosis and treatment.

Keywords: Cesarean Scar Defect (CSD); Cesarean Section Complications; Dyspareunia; Endometriosis; Hypermenorrhea; Laparoscopy; Retroflexio Uteri; Retrograde Menstruation; Uterine Niche; Uterine Scar Defect.

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Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Fig. 1
Fig. 1
Uterine niche with measurements of the residual and adjacent myometrium.
Fig. 2
Fig. 2
Left: Anterior uterine wall defect resulting in retroflexio uteri Right: Sonographically visible retrograde menstruation.
Fig. 3
Fig. 3
Laparoscopic finding of extragenital endometriosis in a niche patient with retroflexio uteri.
See this image and copyright information in PMC

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