Ep47: The Limitations of the Endometriosis Staging System

The most commonly used endometriosis staging system is the rASRM, which classifies endometriosis into 4 stages. In spite of its prevalent use, this staging system has many limitations, a major one being that it completely leaves out Extra Pelvic Endometriosis! We discuss some flaws of the rASRM, and chat about two other classification systems called the EFI and the Enzian system. We also share the Amy and Brittany Classification Staging System that we came up with, which involves a screaming toddler and apples.

**UPDATE November 2021: Since airing this episode, a new staging system was developed called the AAGL 2021 Endometriosis Classification, which was specifically designed to measure surgical complexity. Like the ASRM classification, the stage does not correlate to the patient’s pain, and the staging system doesn’t attempt to give fertility outcomes. However, there is hope that it will help in the future with surgical reimbursements and improve financial incentives to completely treat disease, especially in complex cases needing significant expert time and effort. The staging system is available as an app called AAGL Endo Classification which you can download to your phone. What I like about the app is that the surgeon goes through the different areas of (abdominal) endo, determining if you have no endo there or less/more than 3 cm. Anatomic locations include: peritoneal, left/right ovary, L/R fallopian tube, L/R uterer, bladder, cul-de-sac obliteration, vagina, retrocervical, rectovaginal septum, rectum/sigmoid colon, small bowel/cecum, appendix. Then after they can download a PDF for you to see the locations/depth of your endo. 

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SOURCES: Clickable links at insixteenyears.com/episode47

Video: The Stages of Endometriosis explained by Dr. Cook – Dr. Cook is an excision surgeon at Vital Health Endometriosis. You can also see the rASRM staging system here.

Extrapelvic Not Rare – a non-profit organization run by Wendy Bingham. Well-researched facts and informative videos on the body systems it affects and statistics.

Stages of Endometriosis – Article on endometriosis.net.

The rASRM score and the Enzian classification for endometriosis: their strengths and weaknesses. Dietmar Haas, Omar Shebl, Andreas Shamiyeh, Peter Oppelt. First published: 13 October 2012. https://doi.org/10.1111/aogs.12026.

How to improve the current ASRM classification of endometriosis? 

MR Imaging in Deep Pelvic Endometriosis: A Pictorial Essay – Antônio Coutinho, Jr, Leonardo Kayat Bittencourt , Cíntia E. Pires, Flávia Junqueira, Cláudio Márcio Amaral de Oliveira Lima, Elisa Coutinho, Marisa A. Domingues, Romeu C. Domingues, Edson Marchiori. Published Online:Mar 7 2011. https://doi.org/10.1148/rg.312105144

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