Journal of the European Society for Gynaecological Endoscopy


Heterogeneity of endometriosis lesions requires individualisation of diagnosis and treatment and a different approach to research and evidence based medicine

P.R. Koninckx 1,2,3, A. Ussia 2,4, L. Adamyan 5, A. Wattiez 1,6, V. Gomel 7, D.C. Martin 8

1 Latifa Hospital, Dubai, United Arab Emirates;
2 Professor emeritus OBGYN, KULeuven Belgium, University of Oxford-Hon Consultant, UK, University Cattolica, Roma, Moscow State Univ.;
3 Gruppo Italo Belga, Villa Del Rosario Rome Italy;
4 Consultant Università Cattolica, Roma Italy;
5 Department of Operative Gynecology, Federal State Budget Institution V. I. Kulakov Research Centre for Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia; and e Department of Reproductive Medicine and Surgery, Moscow State University of Medicine and Dentistry, Moscow, Russia;
6 Professor Department of obstetrics and gynaecology, University of Strasbourg;
7 Professor emeritus Department of Obstetrics and Gynecology, University of British Columbia and Women’s Hospital, Vancouver, BC, Canada;
8 Professor emeritus School of Medicine, University of Tennessee Health Science Centre, Memphis Tennessee, USA; Institutional Review Board, Virginia Commonwealth University, Richmond, Virginia. USA.


endometriosis, heterogeneity, evidence based medicine, medical treatment, statistics

Published online: Jan 24 2020


Statistical significance is used to analyse research findings and is together with biased free trials the cornerstone of evidence based medicine. However traditional statistics are based on the assumption that the population investigated is homogeneous without smaller hidden subgroups.

The clinical, inflammatory, immunological, biochemical, histochemical and genetic-epigenetic heterogeneity of similar looking endometriosis lesions is a challenge for research and for diagnosis and treatment of endometriosis. The conclusions obtained by statistical testing of the entire group are not necessarily valid for subgroups. The importance is illustrated by the fact that a treatment with a beneficial effect in 80% of women but with exactly the same but opposite effect, worsening the disease in 20%, remains statistically highly significant.

Since traditional statistics are unable to detect hidden subgroups, new approaches are mandatory. For diagnosis and treatment it is suggested to visualise individual data and to pay specific attention to the extremes of an analysis. For research it is important to integrate clinical, biochemical and histochemical data with molecular biological pathways and genetic-epigenetic analysis of the lesions.

Erratum (in references)

Original article: Facts Views Vis ObGyn. 2019;11(1): 57-61