What to choose and why to use – a critical review on the clinical relevance of rASRM, EFI and Enzian classifications of endometriosis

Abstract

Background: Endometriosis is a common benign gynaecological disease that affects pelvic structures and causes adhesions. Endometriosis outside the pelvis exists but is rarer. Deep endometriosis may affect organs such as the urinary bladder, ureters, bowel and sacral roots. Adenomyosis (growth of endometrium in the myometrium, sometimes explained by disruption of the uterine junctional zone) frequently co-exists with deep endometriosis. Over the past decades, multiple attempts have been made to describe the anatomical extent of endometriosis. Out of approximately 20 classification systems suggested and published so far, three have gained widespread acceptance. These are the rASRM (American Society of Reproductive Medicine) classification, the Endometriosis Fertility Index (EFI) and the Enzian classification. Ideally, a classification system should be useful both for describing disease extent based on surgical findings and results of imaging methods (ultrasound, magnetic resonance imaging). Objectives: To highlight the advantages and disadvantages of the three classification systems. Methods: This is a narrative review based on selected publications and experience of the authors. We discuss the current literature on the use of the rASRM, EFI and Enzian classification systems for describing disease extent with imaging methods and for prediction of fertility, surgical complexity, and risk of surgical complications. We underline the need for one universally acceptable terminology to describe the extent of endometriosis. Conclusions: A useful classification system for endometriosis should describe the sites and extent of the disease, be related to surgical complexity and to disease-associated symptoms, including subfertility and should satisfy needs of both, imaging specialists for pre-operative classification and surgeons. The need for such a system is obvious and is provided by the #Enzian classification. Future research is necessary to test its validity.

Endometriosis classification/staging and terminology- Are we getting closer to finding a universally accepted language?

“…The EQUSUM electronic surgical data collection system seems to perform better than nondigital recording in staging the disease ( Metzemaekers et al, 2020 ) Does the answer lie in finding the right combination of proposed systems? Hudelist et al ( 2021 ) feel this is not practical with the combination of #Enzian, rASRM and EFI and we agree. But we can explore other possibilities.…”

“…In this issue, three articles have focused on endometriosis classification and terminology ( International Working Group of American Association of Gynecologic Laparoscopists (AAGL), European Society for Gynaecological Endoscopy (ESGE), European Society of Human Reproduction and Embyology (ESHRE) and World Endometriosis Society (WES), 2021a ; International Working Group of AAGL, ESGE, ESHRE and WES, 2021b ; Hudelist et al, 2021 ). These articles touch on different aspects of the topic but they all have a common message: a universally accepted endometriosis “language” is urgently needed.…”

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“…The EQUSUM electronic surgical data collection system seems to perform better than nondigital recording in staging the disease (Metzemaekers et al, 2020) Does the answer lie in finding the right combination of proposed systems? Hudelist et al (2021) feel this is not practical with the combination of #Enzian, rASRM and EFI and we agree. But we can explore other possibilities.…”

“…In this issue, three articles have focused on endometriosis classification and terminology (International Working Group of American Association of Gynecologic Laparoscopists (AAGL), European Society for Gynaecological Endoscopy (ESGE), European Society of Human Reproduction and Embyology (ESHRE) and World Endometriosis Society (WES), 2021a; International Working Group of AAGL, ESGE, ESHRE and WES, 2021b;Hudelist et al, 2021). These articles touch on different aspects of the topic but they all have a common message: a universally accepted endometriosis "language" is urgently needed.…”

Expert opinion on the use of transvaginal sonography for presurgical staging and classification of endometriosis

“…The rASRM classification, which has been in use over decades, primarily focuses on the effects of endometriosis on fertility in association with peritoneal and ovarian disease and secondary adhesions. This excludes the detailed description of DE which is considered the main disadvantage of this score [44,47]. Nevertheless, there have been attempts to use TVS in combination with the rASRM score.…”