Endometriosis classification
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Joseph Nasr, M.D.[2] Aravind Kuchkuntla, M.B.B.S[3]
Overview
Endometriosis is classified into four stages of severity based on the revised American Society for Reproductive Medicine scoring system. The staging is based on the distribution of the lesions and the presence of adhesions.
Classification
revised American Society for Reproductive Medicine scoring system (rASRM):[1]
- Stage I:
- Stage II:
- Mild endometriosis lesions are superficial with size less than 5 cm on aggregate
- Lesions scattered on the peritoneum and ovaries
- No significant adhesions present
- Stage III:
- Stage IV:
- Severe disease characterized by multiple superficial and deep implants
- Large ovarian endometriomas
- Dense adhesions present
Anatomical (Phenotype-based) Classification:
Endometriosis is classified based on anatomical phenotype (subtype) rather than disease stage. It is categorized into four subtypes:
- Superficial peritoneal endometriosis
- Deep endometriosis
- Ovarian endometriomas
- Extrapelvic endometriosis
Subtypes may occur alone or in combination and are clinically important because they influence diagnostic evaluation and treatment approach.
The prevalence of individual subtypes in the general population is unknown.
1. Superficial Peritoneal Endometriosis
Superficial peritoneal endometriosis consists of lesions located on the peritoneal surface or serosa of abdominal or pelvic viscera.
Lesions may vary in appearance and may be blue, brown, red, white, or clear.
Superficial peritoneal lesions are often difficult to detect with imaging. Transvaginal ultrasound has low sensitivity for superficial peritoneal disease (65%, 95% CI, 27%–100%).[2]
2. Deep Endometriosis
Deep endometriosis refers to lesions that penetrate beneath the peritoneal surface or infiltrate the muscularis propria of pelvic organs such as the bowel, bladder, or ureter.
These lesions commonly involve the uterosacral ligaments and rectosigmoid colon and may present as nodular lesions with associated fibrosis and adhesions.
Pain severity does not generally correlate with lesion number, location, or subtype; however, deep disease in the posterior cul-de-sac correlates with dyspareunia.[3][4]
Transvaginal ultrasound has moderate sensitivity for detecting deep endometriosis (79%, 95% CI, 69%–89%).[2]
Magnetic resonance imaging using an endometriosis-specific protocol has reported sensitivity of 91%–93.5% and specificity of 86%–87.5% for deep and ovarian endometriosis when compared with laparoscopy or other imaging modalities.[5]
3. Ovarian Endometriomas
Ovarian endometriomas are cystic lesions within the ovary lined by endometrial glands and stroma. They characteristically contain dark, blood-stained fluid and are sometimes referred to as “chocolate cysts.”
Transvaginal ultrasound has high diagnostic accuracy for ovarian endometriomas, with sensitivity of 93% (95% CI, 87%–99%) and specificity of 96% (95% CI, 92%–99%).[2]
MRI similarly demonstrates high sensitivity (91%–93.5%) and specificity (86%–87.5%) for ovarian endometriosis.[5]
4. Extrapelvic Endometriosis
Extrapelvic endometriosis refers to lesions occurring outside of the pelvis. Lesions have been reported in nearly every organ system, including:
- Diaphragm
- Thoracic cavity
- Abdominal wall
- Brain[6]
Clinical manifestations depend on lesion location and may include catamenial pneumothorax, hemoptysis, shoulder pain during menses, or cyclic pain in abdominal wall nodules.[6]
Clinical Relevance of Subtype Classification
Although classification by subtype assists in determining imaging strategy and surgical planning, lesion subtype does not reliably predict pain severity. With the exception of deep posterior cul-de-sac disease and dyspareunia, pain intensity does not correlate with lesion number, location, or subtype.[3][4]
References
- ↑ Adamson GD (2011). "Endometriosis classification: an update". Curr Opin Obstet Gynecol. 23 (4): 213–20. doi:10.1097/GCO.0b013e328348a3ba. PMID 21666464.
- ↑ 2.0 2.1 2.2 Nisenblat V, Bossuyt PM, Farquhar C, Johnson N, Hull ML. Imaging modalities for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev. 2016;2(2):CD009591. doi:10.1002/14651858.CD009591.pub2
- ↑ 3.0 3.1 Pashkunova D, Darici E, Senft B, et al. Lesion size and location in deep infiltrating bowel endometriosis: correlation with gastrointestinal dysfunction and pain. Acta Obstet Gynecol Scand. 2024;103(9):1764-1770. doi:10.1111/aogs.14921
- ↑ 4.0 4.1 Vercellini P, Fedele L, Aimi G, Pietropaolo G, Consonni D, Crosignani PG. Association between endometriosis stage, lesion type, patient characteristics and severity of pelvic pain symptoms: a multivariate analysis of over 1000 patients. Hum Reprod. 2007;22(1):266-271. doi:10.1093/humrep/del339
- ↑ 5.0 5.1 Avery JC, Knox S, Deslandes A, et al; Imagendo Study Group. Noninvasive diagnostic imaging for endometriosis, 2: a systematic review of recent developments in magnetic resonance imaging, nuclear medicine and computed tomography. Fertil Steril. 2024;121(2):189-211. doi:10.1016/j.fertnstert.2023.12.017
- ↑ 6.0 6.1 AndresMP, Arcoverde FVL, Souza CCC, Fernandes LFC, Abrão MS, Kho RM. Extrapelvic endometriosis: a systematic review. J Minim Invasive Gynecol. 2020;27(2):373-389. doi:10.1016/j.jmig.2019.10.004