How to improve the current ASRM classification of endometriosis?

Revised ASRM is not accurate for planning surgery of patients with endometriosis.

Key Points

Highlights:

• Revised 1996 Endometriosis Classification of the American Fertility Society (rASRM) does not always predict the actual stage of endometriosis because  DE (deep endometriosis) may be present in almost half of all endometriosis cases and cause more severe symptoms compared to the superficial endometriosis. Current rASRM endometriosis staging fails to predict the histopathological findings, pregnancy outcome, the location of the disease for appropriate surgical planning and prognosis of the disease.
• To improve the current classification system according to pain symptoms of patients with endometriosis is essential.

Importance:

• Improving the current worldwide accepted rASRM classification system of endometriosis should be performed in coming years.

What's done here:

• Although the rASRM classification system of endometriosis worldwide accepted, authors, give examples from the literature to indicate the limitations of this scoring system.

Key Results:

• The ideal classification system for endometriosis should be accessible, reproducible, and easy to perform, should provide the information about the severity and type of endometriosis,  should show a correlation between the severity and type of symptoms, and also expected to provide prognostic information.
• Regarding these criteria, nor rASRM, neither revised Enzian 2012 classification system of the German Foundation of Endometriosis, could accurately be used. Thus, efforts should be made within related societies to achieve an ideal system for classification of endometriosis.

Limitations:

• Variable pain threshold of the patients that are not related to the severity and the depth of deep infiltrating endometriotic lesions can procreate limitations on pain scaling system.

Lay Summary

In this article which recently published in Best Practice&Research Clinical Obst&Gyn.  from the University of Sao Paulo, Brazil, Andres et al.  penned a review of the classification of endometriosis in chronological order, and discussed the limitations of existing classification systems to indicate a new and better one.

An ideal endometriosis classification system should be reachable, reproducible, easy to perform, should provide the information about the severity and type of endometriosis, and further, the severity and type of symptom including pain and infertility should show a correlation, and also expected to provide prognostic information.

Authors defined the rASRM scoring system of American Fertility Society as well as the revised Enzian classification system of the German Foundation of Endometriosis, and call attention to their limitations evaluating the patients' clinic.

rASRM have a poor correlation when compared to the histopathological findings, and symptoms of patients with acyclic pelvic pain, deep dyspareunia, dysmenorrhea, and is also does not correlate with pregnancy outcome. Deep infiltrating endometriosis can involve bladder, bowel, retro-cervical space, vagina and ureter, thus they cannot be scored in this system, because they are out of surgeon's sight. The limitation of the Enzian 2012 classification system is, it's complexity to patient's comprehension.

On the other hand, EFI (endometriosis infertility index) was published in 2010 to give a prognostic score to asses the issue related to infertility. 

The conclusion by the authors is "The biggest challenge of classifying endometriosis is to correlate the staging of disease to the two most relevant clinical features infertility and pain. This information is crucial for a complete endometriosis classification system, as mentioned in a recently published consensus from the World Endometriosis Society (WES). The rASRM scoring system lacks on those two issues. Efforts should be made within related societies to achieve an ideal system for the classification of endometriosis either to improve the available systems to include the level of pain or to develop a new system that would complement the existent systems".

In order to set up all these multitudes of classification and complexity, renovation of the classification of endometriosis system appear to be essential.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/30029959