Corona et al, in a large retrospective review of the histopathological findings after hysterectomy found that the frequency of unsupportive pathology was higher in women aged younger than 40 years and highest among women with endometriosis or chronic pain.

Pelvic congestion syndrome is a well-recognized cause chronic pelvic pain. Beard et al studied 35 women with pelvic pain, no laparoscopic pathology (endometriosis or old pelvic inflammatory disease), and demonstrable congestion on pelvic venography. The mean age of their patients was 32.4 years (range, 21–41 years). Abnormal adenexal vascularity was not an outcome in the study of Corona et al.

Traditional histological preparation of tissues in cases of suspected endometriosis has a significant false-negative rate. Most published series from respectable units have found that more than one third of surgically obtained biopsies for suspected endometriosis are histologically negative on hematoxylin and eosin staining, with higher rates of negativity with lower graded disease.

Brosens reported that in up to one third of chocolate cysts, no specific pathology can be found. We and others have described ovaries with chocolate cysts and negative for endometrial epithelium yet positive immunohistochemical staining for CD10, a marker for endometrial stromal cells.

Groisman and Meir retrospectively studied 20 cases of histologically equivocal endometriosis (suspicious of, suggestive of, or compatible with) and found that 85% stained positive for CD10, confirming the diagnosis. Potlog-Nahari et al, using CD10 in 31 women with chronic pelvic pain, found the technique almost doubled their diagnosis of stage I endometriosis. We found that of the 31 histologically (hematoxylin and eosin) negative patients, 24 (77%) were found to be CD10 positive. Corona et al did not use immunohistochemical staining for CD10.

These facts, I believe, call into question the therapeutic conclusions in the study of Corona et al.