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Cited by 107Endometriosis Research and TreatmentEctopic Pregnancy Diagnosis and ManagementGynecological conditions and treatments

Extra-pelvic endometriosis: a review.

Open access
Hirata, Tetsuya, Koga, Kaori, Osuga, Yutaka·2020·Reproductive Medicine and Biology
DOI 10.1002/rmb2.12340PMC PMC7542014
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Abstract

Background: Extra‐pelvic endometriosis is a rare type of endometriosis, which occurs in a distant site from gynecological organs. The diagnosis of extra‐pelvic endometriosis can be extremely challenging and may result in a delay in diagnosis. The main objective of this review was to characterize abdominal wall endometriosis (AWE) and thoracic endometriosis (TE). Methods: The authors performed a literature search to provide an overview of AWE and TE, which are the major types of extra‐pelvic endometriosis. Main findings: Abdominal wall endometriosis includes scar endometriosis secondary to the surgical wound and spontaneous AWE, most of which occur in the umbilicus or groin. Surgical treatment appeared to be effective for AWE. Case reports indicated that the diagnosis and treatment of catamenial pneumothorax or endometriosis‐related pneumothorax (CP/ERP) are challenging, and a combination of surgery and postoperative hormonal therapy is essential. Further, catamenial hemoptysis (CH) can be adequately managed by hormonal treatment, unlike CP/ERP. Conclusion: Evidence‐based approaches to diagnosis and treatment of extra‐pelvic endometriosis remain immature given the low prevalence and limited quality of research available in the literature. To gain a better understanding of extra‐pelvic endometriosis, it would be advisable to develop a registry involving a multidisciplinary collaboration with gynecologists, general surgeons, and thoracic surgeons.

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Written from the paper’s full text.

TL;DR

This review characterizes extra-pelvic endometriosis, focusing on abdominal wall endometriosis (AWE) and thoracic endometriosis (TE). It concludes that evidence-based diagnosis and treatment remain immature because of low prevalence and limited research quality.

Key findings

  • AWE includes scar, umbilical, and inguinal endometriosis. In a review of 445 AWE cases, 57% were associated with prior cesarean section, 11% with hysterectomy, 13% with other surgery, and 20% were spontaneous; spontaneous cases were preferentially umbilical or inguinal. Postoperative recurrence was 4.5%–11.2% for scar endometriosis, approximately 10% after local resection of umbilical endometriosis, and 0%–16.6% for inguinal endometriosis.
  • Umbilical endometriosis was more often primary: 66.7% of 96 pathologically diagnosed patients had no prior surgery, and another case series reported 67.6% without surgical history. Symptoms included swelling in 86.5%–90.9%, pain in 80.5%–81.3%, and bleeding in 44.8%–49.2%; in one recent report, dienogest, GnRH agonist, and oral contraceptives improved symptoms in 91.7%, 81.8%, and 57.1% of patients, respectively.
  • Inguinal endometriosis predominantly develops in the right groin, with average age at diagnosis approximately 37 years. MRI showed hyperintensities on T1-weighted or fat-saturated T1-weighted images in 17 of 18 patients; dienogest (2 mg/d) improved groin pain in 6 of 7 patients.
  • Thoracic endometriosis most commonly presents as catamenial pneumothorax (CP), occurring in 72%–73% of TE patients. CP is defined as recurrent pneumothorax (at least two episodes) within 72 hours of menstruation; 20%–35% of spontaneous pneumothorax in reproductive-aged women is reported as CP, over 90% of CP occurs on the right side, and 50%–84% of CP patients have concomitant pelvic endometriosis. Postoperative recurrence of CP/endometriosis-related pneumothorax is 14.3%–46.7%, whereas catamenial hemoptysis has equivalent laterality, lower association with pelvic endometriosis, and responds to hormonal treatment.

Methods

  • Design: narrative review based on a literature search to provide an overview of AWE and TE, the major types of extra-pelvic endometriosis.
  • Data: published literature including case reports, case series, systematic reviews, national survey data, and national inpatient data cited by the authors.
  • Analysis: descriptive synthesis of etiology, clinical presentation, diagnosis, and management; no formal meta-analysis or systematic search strategy is described in the paper.

Limitations

  • Stated: evidence-based approaches to diagnosis and treatment of extra-pelvic endometriosis remain immature given low prevalence and limited quality of research; management of CP/endometriosis-related pneumothorax is not satisfactory, with high recurrence rates, and further research is required.
  • Evident from the text: the review is narrative and does not report a systematic search strategy, inclusion criteria, or formal quality assessment; many conclusions rely on case reports, retrospective series, and heterogeneous published data.

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Integrity signals

Registry

Crossref · 10.1002/rmb2.12340

Cites

110 of 110 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 165 cited sources checked · 0 supported · 0 flagged

  • Findingcitation

    The authors experienced a case of mixed endometrioid and clear cell carcinoma arising from laparoscopic trocar site endometriosis.

    “We experienced a case of mixed endometrioid and clear cell carcinoma arising from laparoscopic trocar site endometriosis.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] Tsuruga T, Hirata T, Akiyama I, et al. Mixed endometrioid and clear cell carcinoma arising from laparoscopic trocar site endometriosis. J Obstet Gynaecol Res. 2019; 45(8): 1613‐ 1618. 31183953 source

      Not checked in the free run.

  • Findingown data

    In the authors' case series, in 17 of 18 patients who underwent MRI, hyperintensities were seen in T1-weighted or fat-saturated T1-weighted images.

    “In our case series, in 17 of 18 patients who underwent MRI, hyperintensities were seen in T1‐weighted images or fat‐saturated T1‐weighted images.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [57] Arakawa T, Hirata T, Koga K, et al. Clinical aspects and management of inguinal endometriosis: a case series of 20 patients. J Obstet Gynaecol Res. 2019; 45(10): 2029‐ 2036. 31381248 source

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  • Findingcitation

    Of 370 reported patients with diaphragmatic lesions, coagulation of lesions was performed in 27.2% (101/370).

    “coagulation of lesions in 27.2% (101/370) of cases.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] Andres MP, Arcoverde FVL, Souza CCC, Fernandes LFC, Abrao MS, Kho RM. Extrapelvic endometriosis: a systematic review. J Minim Invasive Gynecol. 2020; 27(2): 373‐ 389. 31618674 source

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  • Findingcitation

    Among pulmonary endometriosis surgeries, pulmonary parenchymal resection was performed in 73.9%.

    “involved pulmonary parenchymal resection (73.9%)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] Andres MP, Arcoverde FVL, Souza CCC, Fernandes LFC, Abrao MS, Kho RM. Extrapelvic endometriosis: a systematic review. J Minim Invasive Gynecol. 2020; 27(2): 373‐ 389. 31618674 source

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  • Findingcitation

    For pulmonary endometriosis, surgery was performed in 23 of 28 patients.

    “For cases of pulmonary endometriosis, surgery was performed in 23 of 28 patients”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] Andres MP, Arcoverde FVL, Souza CCC, Fernandes LFC, Abrao MS, Kho RM. Extrapelvic endometriosis: a systematic review. J Minim Invasive Gynecol. 2020; 27(2): 373‐ 389. 31618674 source

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  • May combine two claims. 44
  • Classified as probably not a substantial claim. 14

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    Findingown data

    The patient was 49 years old at diagnosis, 180 months after laparoscopic surgery for endometriosis.

    “The patient was 49 years old at diagnosis, 180 months after laparoscopic surgery for endometriosis.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] Tsuruga T, Hirata T, Akiyama I, et al. Mixed endometrioid and clear cell carcinoma arising from laparoscopic trocar site endometriosis. J Obstet Gynaecol Res. 2019; 45(8): 1613‐ 1618. 31183953 source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    In the authors' recent report, dienogest, a GnRH agonist, and OC were effective for improving symptoms in 91.7%, 81.8%, and 57.1% of umbilical endometriosis patients, respectively.

    “In our recent report, dienogest, a GnRH agonist, and OC were effective for improving symptoms in 91.7%, 81.8%, and 57.1% of patients, respectively.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [44] Hirata T, Koga K, Kitade M, et al. A national survey of umbilical endometriosis in Japan. J Minim Invasive Gynecol. 2020; 27(1): 80‐ 87. 30965115 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    Among pulmonary endometriosis surgeries, pleural resection was performed in 4.3%.

    “pleural resection (4.3%)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] Andres MP, Arcoverde FVL, Souza CCC, Fernandes LFC, Abrao MS, Kho RM. Extrapelvic endometriosis: a systematic review. J Minim Invasive Gynecol. 2020; 27(2): 373‐ 389. 31618674 source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    Age, prevalence of endometriosis, number of hospitalizations, and frequency of surgery were significantly higher in CP patients compared to non-CP patients.

    “In addition, age, prevalence of endometriosis, number of hospitalizations, and frequency of surgery were significantly higher in CP patients compared to non‐CP patients.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    A comparison of CP and non-CP of reproductive-aged women revealed that CP occurred approximately 10 times more often on the right side than on the left side, whereas in non-CP, the left and right frequencies were equivalent.

    “a comparison of CP and non‐CP of reproductive‐aged women revealed that CP occurred approximately 10 times more often on the right side than on the left side, whereas in non‐CP, the left and right frequencies were equivalent.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Recurrence rate after hormonal therapy alone was reported to be more than 50%, which is inferior to surgical therapy.

    “the recurrence rate after hormonal therapy alone was reported to be more than 50%, which is inferior to surgical therapy.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [69] Joseph J, Sahn SA. Thoracic endometriosis syndrome: new observations from an analysis of 110 cases. Am J Med. 1996; 100(2): 164‐ 170. 8629650 source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    Among pulmonary endometriosis surgeries, lobectomy was performed in 21.7%.

    “lobectomy (21.7%)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] Andres MP, Arcoverde FVL, Souza CCC, Fernandes LFC, Abrao MS, Kho RM. Extrapelvic endometriosis: a systematic review. J Minim Invasive Gynecol. 2020; 27(2): 373‐ 389. 31618674 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Findingown data

    From data of approximately 42 million hospitalization cases, information on 12371 men and 27716 women with PSP was extracted.

    “From data of approximately 42 million hospitalization cases, information on 12371 men and 27716 women with PSP was extracted.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The age distribution of female patients with PSP had three peaks: 18, around 40, and 80 years, while male patients showed two peaks: 18 and 80 years old.

    “The age distribution of female patients with PSP had three peaks: 18, around 40, and 80 years, while male patients showed two peaks: 18 and 80 years old.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Findingnone given

    The number of case reports of extra-pelvic endometriosis has increased.

    “The number of case reports of extra‐pelvic endometriosis has increased.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Catamenial hemoptysis (CH) can be adequately managed by hormonal treatment, unlike CP/ERP.

    “catamenial hemoptysis (CH) can be adequately managed by hormonal treatment, unlike CP/ERP.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    Diagnosis of extra-pelvic endometriosis can be extremely challenging and may result in a delay in diagnosis.

    “The diagnosis of extra‐pelvic endometriosis can be extremely challenging and may result in a delay in diagnosis.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The most widely accepted theory for the pathogenesis of endometriosis is retrograde menstruation through the fallopian tubes into the pelvic cavity.

    “The most widely accepted theory for the pathogenesis of endometriosis is retrograde menstruation through the fallopian tubes into the pelvic cavity.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [4] Sampson JA. Peritoneal endometriosis due to the menstrual dissemination of endometrial tissue into the peritoneal cavity. Am J Obstet Gynecol. 1927; 14(4): 422‐ 469. source

      Not checked in the free run.

  • May combine two claims.

    Premisenone given

    Abdominal wall endometriosis includes scar endometriosis secondary to surgical wound and spontaneous AWE, most of which occur in the umbilicus or groin.

    “Abdominal wall endometriosis includes scar endometriosis secondary to the surgical wound and spontaneous AWE, most of which occur in the umbilicus or groin.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Endometriotic lesions in AWE have been reported to involve the adipose layer (91.4%-96.9%), fascia (65.7%-67.2%), and muscular layer (17.2%-20.7%).

    “Endometriotic lesions have been reported to involve the adipose layer (91.4%‐96.9%), fascia (65.7%‐67.2%), and muscular layer (17.2%‐20.7%).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [15] Ecker AM, Donnellan NM, Shepherd JP, Lee TT. Abdominal wall endometriosis: 12 years of experience at a large academic institution. Am J Obstet Gynecol. 2014; 211(4): 363.e1‐ 363.e5. 24732005 source

      Not checked in the free run.

    • cites [19] Zhang P, Sun Y, Zhang C, et al. Cesarean scar endometriosis: presentation of 198 cases and literature review. BMC Womens Health. 2019; 19(1): 14. 30658623 PMC6339338 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Oral contraceptives, progestin, or GnRH agonists may be effective in improving symptoms of AWE and can be an option for patients who do not want surgery.

    “Oral contraceptives (OC), progestin, or gonadotropin‐releasing hormone (GnRH) agonists may be effective in improving symptoms and can be an option for patients who do not want surgery.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [16] Carsote M, Terzea DC, Valea A, Gheorghisan‐Galateanu AA. Abdominal wall endometriosis (a narrative review). Int J Med Sci. 2020; 17(4): 536‐ 542. 32174784 PMC7053307 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Some iatrogenic endometrioses have a cancer-driving mutation, which may be related to the mechanism of malignant transformation.

    “It has been reported that some iatrogenic endometrioses have a cancer‐driving mutation, 17 which may be related to the mechanism of malignant transformation.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] Lac V, Verhoef L, Aguirre‐Hernandez R, et al. Iatrogenic endometriosis harbors somatic cancer‐driver mutations. Hum Reprod. 2019; 34(1): 69‐ 78. 30428062 PMC6296213 source

      Not checked in the free run.

  • May combine two claims.

    Premisenone given

    The effectiveness of surgical treatment for umbilical endometriosis has been reported, but the outcomes of hormonal therapy have rarely been described.

    “The effectiveness of surgical treatment has been reported, but the outcomes of hormonal therapy have rarely been described.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In a review of 48 cases of malignant transformation of scar endometriosis, the mean age at diagnosis was 46 years, 87.5% were associated with cesarean section, and 12.5% with open uterine surgery.

    “In a review of 48 cases, the mean age at diagnosis was 46 years, 87.5% were associated with cesarean section, and 12.5% were associated with open uterine surgery.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29] Mihailovici A, Rottenstreich M, Kovel S, Wassermann I, Smorgick N, Vaknin Z. Endometriosis‐associated malignant transformation in abdominal surgical scar. Medicine. 2017; 96(49): 1‐ 5. PMC5728970 29245355 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Symptoms of swelling, pain, or bleeding at umbilical endometriosis lesions were present in 86.5%-90.9%, 80.5%-81.3%, or 44.8%-49.2% of cases, respectively.

    “Symptoms of swelling, pain, or bleeding at the lesions were present in 86.5%‐90.9%, 80.5%‐81.3%, or 44.8%‐49.2% of cases, respectively.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [44] Hirata T, Koga K, Kitade M, et al. A national survey of umbilical endometriosis in Japan. J Minim Invasive Gynecol. 2020; 27(1): 80‐ 87. 30965115 source

      Not checked in the free run.

    • cites [46] Victory R, Diamond MP, Johns DA. Villar's nodule: a case report and systematic literature review of endometriosis externa of the umbilicus. J Minim Invasive Gynecol. 2007; 14(1): 23‐ 32. 17218225 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Approximately 70% of patients with umbilical endometriosis did not have a history of prior surgery, suggesting a mechanism other than direct contact implantation.

    “Unlike scar endometriosis, approximately 70% of patients with umbilical endometriosis did not have a history of prior surgery, suggesting a mechanism other than direct contact implantation.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Ultrasonography, CT, and MRI are all useful for diagnostic imaging of AWE.

    “Ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) are all useful for diagnostic imaging.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [21] Gidwaney R, Badler RL, Yam BL, et al. Endometriosis of abdominal and pelvic wall scars: multimodality imaging findings, pathologic correlation, and radiologic mimics. RadioGraphics. 2012; 32(7): 2031‐ 2043. 23150856 source

      Not checked in the free run.

  • May combine two claims.

    Premisenone given

    The typical symptom of AWE is a painful mass in the abdominal wall, which may be more symptomatic during menstruation.

    “The typical symptom is a painful mass in the abdominal wall, which may be more symptomatic during menstruation.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    In a review of 21 cases of trocar site endometriosis, the average age at diagnosis was 32 years, and the interval between initial laparoscopic surgery and diagnosis was 20.6 months on average.

    “In a review of 21 cases of trocar site endometriosis, the average age at diagnosis was 32 years, and the interval between initial laparoscopic surgery and diagnosis was 20.6 months on average.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Scar endometriosis is considered the most frequent of the abdominal wall endometrioses and may be defined as an iatrogenic endometriosis.

    “Scar endometriosis is considered to be the most frequent of the abdominal wall endometrioses and may be defined as an iatrogenic endometriosis.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] Lac V, Verhoef L, Aguirre‐Hernandez R, et al. Iatrogenic endometriosis harbors somatic cancer‐driver mutations. Hum Reprod. 2019; 34(1): 69‐ 78. 30428062 PMC6296213 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In a review of 445 AWE cases, 57% were associated with prior cesarean section, 11% with hysterectomy, and 13% with other surgery.

    “A review describing 445 cases of AWE revealed that 57%, 11%, and 13% of cases were associated with a prior cesarean section, hysterectomy, and other surgery, respectively.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] Horton JD, DeZee KJ, Ahnfeldt EP, Wagner M. Abdominal wall endometriosis: a surgeon's perspective and review of 445 cases. Am J Surg. 2008; 196(2): 207‐ 212. 18513698 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The frequency of AWE has been estimated to be 0.04%-5.5%.

    “The frequency of AWE has been estimated to be 0.04%‐5.5%.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [11] Horton JD, DeZee KJ, Ahnfeldt EP, Wagner M. Abdominal wall endometriosis: a surgeon's perspective and review of 445 cases. Am J Surg. 2008; 196(2): 207‐ 212. 18513698 source

      Not checked in the free run.

    • cites [12] Dwivedi AJ, Agrawal SN, Silva YJ. Abdominal wall endometriomas. Digest Dis Sci. 2002; 47(2): 456‐ 461. 11855568 source

      Not checked in the free run.

    • cites [13] Singh K, Lessells A, Adam D, et al. Presentation of endometriosis to general surgeons: a 10‐year experience. Br J Surg. 1995; 82(10): 1349‐ 1351. 7489161 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Fine-needle aspiration can confirm the preoperative diagnosis of AWE, excluding malignancy.

    “Fine‐needle aspiration can confirm the preoperative diagnosis of AWE, excluding malignancy.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] Rindos NB, Mansuria S. Diagnosis and management of abdominal wall endometriosis: a systematic review and clinical recommendations. Obstet Gynecol Surv. 2017; 72(2): 116‐ 122. 28218772 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The average time between initial surgery and diagnosis of endometriotic malignant transformation was 19.3 years, suggesting a slow evolution of the disease.

    “The average time between initial surgery and diagnosis of endometriotic malignant transformation was 19.3 years, which suggested a slow evolution of the disease.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [29] Mihailovici A, Rottenstreich M, Kovel S, Wassermann I, Smorgick N, Vaknin Z. Endometriosis‐associated malignant transformation in abdominal surgical scar. Medicine. 2017; 96(49): 1‐ 5. PMC5728970 29245355 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Clear cell carcinoma (66.7%) was the most common histological type in malignant transformation of scar endometriosis, followed by endometrioid carcinoma (14.6%).

    “Regarding the histological type, clear cell carcinoma (66.7%) was the most common, followed by endometrioid carcinoma (14.6%).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29] Mihailovici A, Rottenstreich M, Kovel S, Wassermann I, Smorgick N, Vaknin Z. Endometriosis‐associated malignant transformation in abdominal surgical scar. Medicine. 2017; 96(49): 1‐ 5. PMC5728970 29245355 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Transabdominal ultrasonography can show umbilical endometriosis lesions as low echoic lesions, while CT and MRI are more useful to preoperatively determine the size and extent of lesions.

    “While transabdominal ultrasonography can show lesions as low echoic lesions, CT and MRI are more useful to preoperatively determine the size and extent of lesions.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [49] Mechsner S, Bartley J, Infanger M, Loddenkemper C, Herbel J, Ebert AD. Clinical management and immunohistochemical analysis of umbilical endometriosis. Arch Gynecol Obstet. 2009; 280(2): 235‐ 242. 19116726 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The abdominal fluid containing endometrium circulates clockwise in the abdominal cavity, and the sigmoid colon blocks the abdominal fluid from entering the left inguinal ring.

    “The abdominal fluid containing the endometrium circulates clockwise in the abdominal cavity, and the sigmoid colon blocks the abdominal fluid from entering the left inguinal ring”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [62] Fedele L, Bianchi S, Frontino G, Zanconato G, Rubino T. Radical excision of inguinal endometriosis. Obstet Gynecol. 2007; 110(2 Pt 2): 530‐ 533. 17666654 source

      Not checked in the free run.

    • cites [63] Kiyak G, Ergul E, SarÂkaya SM, Yazgan A. Endometriosis of the groin hernia sac: report of a case and review of the literature. Hernia. 2010; 14(2): 215‐ 217. 19590815 source

      Not checked in the free run.

    • cites [64] Kim DH, Kim MJ, Kim M‐L, Park JT, Lee JH. Inguinal endometriosis in a patient without a previous history of gynecologic surgery. Obstet Gynecol Sci. 2014; 57(2): 172. 24678494 PMC3965704 source

      Not checked in the free run.

  • May combine two claims.

    Premiseown data

    GnRH agonists were effective in over 80% of umbilical endometriosis patients but were unsuitable for long-term administration due to the hypoestrogenic effect.

    “GnRH agonists were effective in over 80% of patients, but were unsuitable for long‐term administration due to the hypoestrogenic effect.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    20%-35% of spontaneous pneumothorax in reproductive-aged women are reported to be CP.

    “Regarding frequency, 20%‐35% of spontaneous pneumothorax in reproductive‐aged women are reported to be CP.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [71] Alifano M, Jablonski C, Kadiri H, et al. Catamenial and noncatamenial, endometriosis‐related or nonendometriosis‐related pneumothorax referred for surgery. Am J Respir Crit Care Med. 2007; 176(10): 1048‐ 1053. 17626909 source

      Not checked in the free run.

    • cites [73] Alifano M, Roth T, Broet SC, Schussler O, Magdeleinat P, Regnard JF. Catamenial pneumothorax: a prospective study. Chest. 2003; 124(3): 1004‐ 1008. 12970030 source

      Not checked in the free run.

    • cites [74] Legras A, Mansuet‐Lupo A, Rousset‐Jablonski C, et al. Pneumothorax in women of child‐bearing age: an update classification based on clinical and pathologic findings. Chest. 2014; 145(2): 354‐ 360. 24091546 source

      Not checked in the free run.

  • May combine two claims.

    Premisenone given

    Most reports of inguinal endometriosis have described surgical treatment, and reports on hormonal therapy alone are very limited.

    “Regarding treatment, most reports have described cases with surgical treatment, and reports on cases receiving hormonal therapy alone are very limited.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The histological types of malignant transformation of umbilical endometriosis were clear cell carcinoma in one case, endometrioid carcinoma in one case, and adenocarcinoma in two cases.

    “The histological types were clear cell carcinoma in one case, endometrioid carcinoma in one case, and adenocarcinoma in two cases.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [44] Hirata T, Koga K, Kitade M, et al. A national survey of umbilical endometriosis in Japan. J Minim Invasive Gynecol. 2020; 27(1): 80‐ 87. 30965115 source

      Not checked in the free run.

    • cites [53] Lauslahti K. Malignant external endometriosis. A case of adenocarcinoma of umbilical endometriosis. Acta Pathol Microbiol Scand Suppl. 1972; 233: 98‐ 102. 4342325

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The mechanism of inguinal endometriosis is often explained mainly by the theory of reflux of menstrual blood into the pelvis.

    “the mechanism is often explained mainly by the theory of reflux of menstrual blood into the pelvis.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [62] Fedele L, Bianchi S, Frontino G, Zanconato G, Rubino T. Radical excision of inguinal endometriosis. Obstet Gynecol. 2007; 110(2 Pt 2): 530‐ 533. 17666654 source

      Not checked in the free run.

    • cites [63] Kiyak G, Ergul E, SarÂkaya SM, Yazgan A. Endometriosis of the groin hernia sac: report of a case and review of the literature. Hernia. 2010; 14(2): 215‐ 217. 19590815 source

      Not checked in the free run.

    • cites [64] Kim DH, Kim MJ, Kim M‐L, Park JT, Lee JH. Inguinal endometriosis in a patient without a previous history of gynecologic surgery. Obstet Gynecol Sci. 2014; 57(2): 172. 24678494 PMC3965704 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Manifestation of TE includes catamenial pneumothorax (CP), catamenial hemothorax, catamenial hemoptysis (CH), and lung nodules.

    “Manifestation of TE includes catamenial pneumothorax (CP), catamenial hemothorax, catamenial hemoptysis (CH), and lung nodules.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [69] Joseph J, Sahn SA. Thoracic endometriosis syndrome: new observations from an analysis of 110 cases. Am J Med. 1996; 100(2): 164‐ 170. 8629650 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Thoracic endometriosis (TE) is a major type of extra-pelvic endometriosis and is characterized by the presence of endometriotic lesions in the thoracic cavity.

    “Thoracic endometriosis (TE) is a major type of extra‐pelvic endometriosis and is characterized by the presence of endometriotic lesions in the thoracic cavity.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [67] Nezhat C, Lindheim SR, Backhus L, et al. Thoracic endometriosis syndrome: a review of diagnosis and management. JSLS. 2019; 23(3): e2019. PMC6684338 31427853 source

      Not checked in the free run.

    • cites [68] Gil Y, Tulandi T. Diagnosis and treatment of catamenial pneumothorax: a systematic review. J Minim Invasive Gynecol. 2020; 27(1): 48‐ 53. 31401265 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The average age at diagnosis of inguinal endometriosis is approximately 37 years old.

    “The average age at diagnosis is approximately 37 years old.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [10] Andres MP, Arcoverde FVL, Souza CCC, Fernandes LFC, Abrao MS, Kho RM. Extrapelvic endometriosis: a systematic review. J Minim Invasive Gynecol. 2020; 27(2): 373‐ 389. 31618674 source

      Not checked in the free run.

    • cites [56] Niitsu H, Tsumura H, Kanehiro T, Yamaoka H, Taogoshi H, Murao N. Clinical characteristics and surgical treatment for inguinal endometriosis in young women of reproductive age. Dig Surg. 2019; 36(2): 166‐ 172. 29975936 source

      Not checked in the free run.

    • cites [57] Arakawa T, Hirata T, Koga K, et al. Clinical aspects and management of inguinal endometriosis: a case series of 20 patients. J Obstet Gynaecol Res. 2019; 45(10): 2029‐ 2036. 31381248 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    CP is the most common clinical presentation of TE, occurring in 72%-73% of TE patients, followed by catamenial hemothorax (12%-14%), CH (7%-12%), and lung nodule (2%-6%).

    “CP is the most common clinical presentation of TE, occurring in 72%‐73% of TE patients, followed by catamenial hemothorax (12%‐14%), CH (7%‐12%), and lung nodule (2%‐6%).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [69] Joseph J, Sahn SA. Thoracic endometriosis syndrome: new observations from an analysis of 110 cases. Am J Med. 1996; 100(2): 164‐ 170. 8629650 source

      Not checked in the free run.

    • cites [70] Channabasavaiah AD, Joseph JV. Thoracic endometriosis: revisiting the association between clinical presentation and thoracic pathology based on thoracoscopic findings in 110 patients. Medicine (Baltimore). 2010; 89(3): 183‐ 188. 20453605 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    It is speculated that endometriosis propagates from the pelvis to the groin via the round ligament.

    “It is also speculated that endometriosis propagates from the pelvis to the groin via the round ligament.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [62] Fedele L, Bianchi S, Frontino G, Zanconato G, Rubino T. Radical excision of inguinal endometriosis. Obstet Gynecol. 2007; 110(2 Pt 2): 530‐ 533. 17666654 source

      Not checked in the free run.

    • cites [63] Kiyak G, Ergul E, SarÂkaya SM, Yazgan A. Endometriosis of the groin hernia sac: report of a case and review of the literature. Hernia. 2010; 14(2): 215‐ 217. 19590815 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Endometrial cells that have reached the right hemidiaphragm adhere to the surface of the right hemidiaphragm or migrate into the thoracic cavity through congenital or acquired fenestration in the diaphragm.

    “It is thought that endometrial cells, which have reached the right hemidiaphragm, adhere to the surface of right hemidiaphragm or migrate into the thoracic cavity through congenital or acquired fenestration in the diaphragm.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [77] Vercellini P, Abbiati A, Vigano P, et al. Asymmetry in distribution of diaphragmatic endometriotic lesions: evidence in favour of the menstrual reflux theory. Hum Reprod. 2007; 22(9): 2359‐ 2367. 17636274 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    MRI has been reported to be superior to CT in diagnosing diaphragmatic, pleural, and hemorrhagic lesions with a reported sensitivity of 83% overall.

    “MRI has been reported to be superior to CT in diagnosing diaphragmatic, pleural, and hemorrhagic lesions with a reported sensitivity of 83% overall.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [86] Rousset P, Gregory J, Rousset‐Jablonski C, et al. MR diagnosis of diaphragmatic endometriosis. Eur Radiol. 2016; 26(11): 3968‐ 3977. 26868500 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Unlike GnRH agonists, GnRH antagonists induce rapid and reversible suppression of ovarian hormone levels without the initial 1- to 2-week flare-up reaction.

    “Unlike GnRH agonists, GnRH antagonists induce rapid and reversible suppression of ovarian hormone levels without the initial 1‐ to 2‐week flare‐up reaction,”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [98] Dun EC, Taylor HS. Elagolix: a promising oral GnRH antagonist for endometriosis‐associated pain. Oncotarget. 2017; 8(59): 99219‐ 99220. 29245894 PMC5725085 source

      Not checked in the free run.

  • May combine two claims.

    Premisereasoning

    CT remains the first-line imaging method for TE because it is readily available and inexpensive.

    “CT remains the first‐line imaging method, because it is readily available and inexpensive.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    None of the proposed theories alone can explain the multipresentation of TE, which is most likely multifactorial.

    “Although the above theories have been proposed, none of the theories alone can explain multipresentation of TE, which is most likely multifactorial.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    The retrograde menstruation theory is the most plausible explanation for how endometrial cells reach the thoracic cavity, as it can explain the role of diaphragmatic endometrial implants.

    “Of these, the retrograde menstruation theory is the most plausible, as it can explain the role of diaphragmatic endometrial implants”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [67] Nezhat C, Lindheim SR, Backhus L, et al. Thoracic endometriosis syndrome: a review of diagnosis and management. JSLS. 2019; 23(3): e2019. PMC6684338 31427853 source

      Not checked in the free run.

    • cites [77] Vercellini P, Abbiati A, Vigano P, et al. Asymmetry in distribution of diaphragmatic endometriotic lesions: evidence in favour of the menstrual reflux theory. Hum Reprod. 2007; 22(9): 2359‐ 2367. 17636274 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Continuous regimens such as dienogest or continuous oral contraceptives lead to avoidance of cyclic bleeding, which may reduce the frequency of catamenial symptoms associated with thoracic endometriosis.

    “These continuous regimens lead to avoidance of cyclic bleeding, which may result in reduction of the frequency of the catamenial symptoms associated with TE.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    CT and chest radiographics are sensitive for the detection of pneumothorax.

    “CT and chest radiographics are sensitive for the detection of pneumothorax.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    The coelomic metaplasia theory can explain plural endometriotic lesions but cannot explain the right-sided predominance.

    “This theory can explain plural endometriotic lesions, but cannot explain the right‐sided predominance.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [73] Alifano M, Roth T, Broet SC, Schussler O, Magdeleinat P, Regnard JF. Catamenial pneumothorax: a prospective study. Chest. 2003; 124(3): 1004‐ 1008. 12970030 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In pathologically diagnosed ERP, 60% occurred during the menstrual period, but 40% occurred during a non-menstrual period.

    “In pathologically diagnosed ERP, 60% occurred during the menstrual period, but 40% occurred during a non‐menstrual period.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [82] Fukuoka M, Kurihara M, Haga T, et al. Clinical characteristics of catamenial and non‐catamenial thoracic endometriosis‐related pneumothorax. Respirology. 2015; 20(8): 1272‐ 1276. 26306694 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Nezhat et al reported that TE was found in diaphragm (100%), chest wall (64%), and parenchyma (64%) using the VATS procedure.

    “Nezhat et al reported that TE was found in diaphragm (100%), chest wall (64%), and parenchyma (64%) using the VATS procedure.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [72] Nezhat C, Main J, Paka C, Nezhat A, Beygui RE. Multidisciplinary treatment for thoracic and abdominopelvic endometriosis. JSLS. 2014; 18(3): e2014. PMC4154426 25392636 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Catamenial pneumothorax or endometriosis-related pneumothorax and catamenial hemoptysis are distinct entities, although both are types of thoracic endometriosis.

    “Accordingly, CP/ERP and CH are suggested to be distinct entities, although both of them are types of TE.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    A review of these reports has partially revealed the features of endometriosis at each site and leads to hypothesize how the causes of endometriosis differ depending on the site.

    “A review of these reports has partially revealed the features of endometriosis at each site and leads to hypothesize how the causes of endometriosis differ depending on the site (Table 1).”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Treatment with a GnRH antagonist may be a candidate for effective hormone therapy for thoracic endometriosis in the future.

    “Thus, treatment with a GnRH antagonist may be a candidate for effective hormone therapy for TE in the future.”
    Quote in the paperSubstantial claim
56 of 56

  • The authors state this as an assumption.

    The previous operation was the trigger for the development of endometriosis.

    “assuming that the previous operation was the trigger for the development of endometriosis.”

  • The paper relies on this without support.

    Malignant transformation involves multifactorial factors such as genetic, immunological, and environmental factors.

    “Malignant transformation involves multifactorial factors such as genetic, immunological, and environmental factors.”

  • The paper relies on this without support.

    GnRH agonists are highly effective in inducing hypogonadotropic hypogonadism and amenorrhea.

    “as they are highly effective in inducing hypogonadotropic hypogonadism and amenorrhea.”

  • The paper relies on this without support.

    Long-term use of GnRH agonist induces hypoestrogenic effects leading to menopausal-like symptoms and osteoporosis, which may result in discontinuation.

    “Long‐term use of GnRH agonist induces hypoestrogenic effects leading to menopausal‐like symptoms and osteoporosis, which may result in discontinuation.”

  • The paper relies on this without support.

    Discontinuation of hormonal therapy is associated with a high rate of recurrence.

    “Discontinuation of hormonal therapy is associated with a high rate of recurrence.”
5 of 5

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Cutaneous endometriosis is the most common subtype encountered by plastic surgeons, usually during open abdominal wall surgery.

    “Despite comprising only 1% of cases, cutaneous endometriosis is the most common subtype encountered by plastic surgeons, usually during open abdominal wall surgery.6,7”

    From Endometriosis in Patients Undergoing Plastic Surgical Procedures: A Case Report and Review of the Literature (2024) · cites this paper as [7]

    The ‘Scar endometriosis’ section says scar endometriosis is the most frequent abdominal-wall form and occurs predominantly at cesarean scars, supporting a link to prior abdominal surgery. It does not say cutaneous endometriosis is the subtype most often encountered by plastic surgeons or that they usually encounter it during open abdominal-wall surgery. The ‘Umbilical endometriosis’ section mentions plastic-surgeon consultation for reconstruction, but not how frequently surgeons encounter the condition. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • Cutaneous endometriosis comprises only 1% of cases.

    “Despite comprising only 1% of cases, cutaneous endometriosis is the most common subtype encountered by plastic surgeons, usually during open abdominal wall surgery.6,7”

    From Endometriosis in Patients Undergoing Plastic Surgical Procedures: A Case Report and Review of the Literature (2024) · cites this paper as [7]

    The Introduction (page unavailable) says endometriosis less commonly affects the abdominal wall, and the Abdominal Wall Endometriosis section (page unavailable) gives an estimated frequency of 0.04%–5.5% for abdominal wall endometriosis. Neither passage says that cutaneous endometriosis comprises 1% of endometriosis cases, so the specific figure is unsupported. (LLM, conf=0.76)

    Experimental — accuracy not yet measured

  • Rare cases of endometriosis are encountered by plastic surgeons in routine practice, either incidentally or as a concomitant finding.

    “Although patients seeking treatment for endometriosis usually present to gynecologists, there are rare cases of endometriosis encountered by plastic surgeons in routine practice, either incidentally or as a concomitant finding.”

    From Endometriosis in Patients Undergoing Plastic Surgical Procedures: A Case Report and Review of the Literature (2024) · cites this paper as [7]

    The Introduction says endometriosis less commonly occurs in the abdominal wall, and the Conclusion calls for collaboration with general and thoracic surgeons (pages not provided). These passages support the broader point that surgeons may encounter extra-pelvic endometriosis, but the review does not establish that plastic surgeons encounter it in routine practice, incidentally or as a concomitant finding. (LLM, conf=0.83)

    Experimental — accuracy not yet measured

  • Certain studies involved oxidative stress with epigenetic alterations in DNA methylation in the pathogenesis of malignant transformation of endometriosis.

    “Even though the pathogenesis of the malignant transformation of endometriosis remains unelucidated, certain studies involved oxidative stress with epigenetic alterations in DNA methylation [1,2,3,4].”

    From Malignancy in Abdominal Wall Endometriosis: Is There a Way to Avoid It? A Systematic Review (2024) · cites this paper as [2]

    The Scar endometriosis section says malignant transformation involves genetic, immunological, and environmental factors, and discusses a possible role for cancer-driving mutations. It does not identify oxidative stress or epigenetic changes in DNA methylation as mechanisms; searches for those terms found no supporting passage. No page number was available in our copy. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • Once in the peritoneal cavity, endometrial cells follow clockwise peritoneal currents from the pelvis to the right paracolic gutter and then toward the right hemidiaphragm.

    “Once in the peritoneal cavity, the endometrial cells follow the clockwise peritoneal currents, which flow from the pelvis to the right paracolic gutter, then finally towards the right hemidiaphragm [ 31 ].”

    From Thoracic Endometriosis Syndrome: A Comprehensive Review and Multidisciplinary Approach to Management (2024) · cites this paper as [31]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • CP classification percentage does not match the count

    Minor

    Thirteen of 156 patients is 8.33%, which rounds to 8.3%, not 8.2%.

    Reported 8.2 · recomputed 8.333333

  • Peak around age 40 is called the third rather than the second peak

    Minor

    The listed female age peaks are 18, around 40, and 80 years. That makes the peak around 40 the second peak, not the third.

2 of 2

Cites

Flagged first, then by citations

3 of the 113 references couldn’t be matched to a known paper.

Cited by

Sorted by citations

Related

Authors
Hirata, T., Koga, K., & Osuga, Y.
Affiliations
The University of Tokyo (JP)
Corresponding author
Hirata, Tetsuya
ORCID
Venue
Reproductive Medicine and Biology
Publisher
Wiley
Published
2020-07-16
Volume
19
Issue
4
Pages
323-333
ISSN
  • 1445-5781 (ISSN-L)
  • 1447-0578
DOI
10.1002/rmb2.12340
PMC
PMC7542014
OpenAlex
W3043640822
Semantic Scholar
32bf567546cb36c29fe5362591c80573103d2874
Cited by
107
References
113
Citations by year
2026: 23 · 2025: 21 · 2024: 19 · 2023: 20 · 2022: 16 · 2021: 7 · 2020: 1
FWCI
9.70
Type
journal article
Language
en
Open access
Licence
Locations
  • Reproductive Medicine and Biology (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
  • the Japanese Agency for Medical Research and Development
  • the Japanese Ministry of Education, Culture, Sports, Science and Technology
Topics
  • Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ectopic Pregnancy Diagnosis and Management
  • Health Sciences › Medicine › Obstetrics and Gynecology › Gynecological conditions and treatments
Keywords
extrapelvic endometriosis, abdominal wall endometriosis, thoracic endometriosis, scar endometriosis, catamenial pneumothorax, catamenial hemoptysis, hormone therapy, surgical treatment, delayed diagnosis

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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