Classification of endometriosis revisited

Endometriosis: Epidemiology, Classification, Pathogenesis, Treatment and Genetics (Review of Literature)

Endometriosis is a “mysterious” disease and its exact cause has not yet been established. Among the etiological factors, congenital, environmental, epigenetic, autoimmune and allergic factors are listed. It is believed that the primary mechanism of the formation of endometriosis foci is retrograde menstruation, i.e., the passage of menstrual blood through the fallopian tubes into the peritoneal cavity and implantation of exfoliated endometrial cells. However, since this mechanism is also observed in healthy women, other factors must also be involved in the formation of endometriosis foci. Endometriosis is in many women the cause of infertility, chronic pain and the deterioration of the quality of life. It also represents a significant financial burden on health systems. The article presents a review of the literature on endometriosis—a disease affecting women throughout the world.

Classification of deep endometriosis (DE) including bowel endometriosis: From r-ASRM to #Enzian-classification

Endometriotic lesions may affect peritoneal and ovarian tissues, cause secondary adhesions, and - in case of deep endometriosis (DE), invade organs such as the urinary bladder, ureters, and bowel. Over decades, several classification systems have been proposed with the rASRM score being the most widely accepted one to date. However, the rASRM classification has certain limitations regarding the description of DE. In contrast, the Enzian classification, which has been updated and modified recently in the form of the so-called #Enzian classification, has proved to be the most suitable tool for staging DE and now also includes peritoneal or ovarian diseases as well as adhesions. In the ideal scenario, a classification for endometriosis can be used with both diagnostic and surgical methods. The present work discusses the pros and cons of scores for endometriosis and highlights the need for using one universal classification system.

Endometriosis

Endometriosis is the presence of functional endometrial tissue outside the uterine cavity and the myometrium. It is an important cause of infertility and pelvic pain in women older than 25 years. Endometriomas are relatively common and can mimic other adnexal masses, and ultrasonography is often the first choice of imaging. This pictorial essay presents the sonographic appearance of endometriomas and similar-appearing adnexal masses and their characteristics, which may aid in their differentiation on routine ultrasonographic examination.

Diagnosis of endometriosis: pelvic endoscopy and imaging techniques

Although laparoscopy is the gold standard for the diagnosis of endometriosis, the need for this invasive diagnostic tool is a major stumbling-block in both effective clinical management and for research into this common and debilitating disease. As visual inspection of the pelvis has also major limitations, particularly for the diagnosis of posterior pelvis, bowel and bladder endometriosis, it is not surprising that considerable efforts are being made to improve the diagnosis by imaging techniques. Peritoneal endometriosis and ovarian endometriomata are predominantly haemorrhagic lesions. During laparoscopy, these lesions are readily identified by the presence of old or recent bleeding. Both transvaginal sonography and magnetic resonance (MR) imaging have a low sensitivity for the diagnosis of peritoneal and ovarian implants and adhesions. Transvaginal sonography is useful in the diagnosis of ovarian endometriomata, providing the diameter is larger than 2 cm. As transvaginal sonography costs less than MR imaging, transvaginal sonography might be the preferred method of confirming a sizeable endometrioma. Posterior pelvis endometriosis is an infiltrating adenomyotic lesion with microendometriomata. High-resolution transvaginal ultrasonography, and in particular MR imaging, are increasingly used to diagnose the presence and extent of infiltrating lesions and the involvement of rectosigmoid and ureters.

Noninvasive diagnosis of endometriosis: the role of imaging and markers

Endometriosis is defined by the presence of endometrial tissue outside the uterus. Clinical and basic research in endometriosis has been hampered severely by the lack of accurate noninvasive diagnostic techniques. Transvaginal ultrasonography, MRI, and endometrial and serum markers have the potential to facilitate the diagnosis and can be useful in the follow-up of patients. Endometriosis research has entered the postgenomic era, and powerful genomic and proteomic technology is being applied in the search for novel diagnostic and therapeutic approaches. This article explores the recent advances in imaging techniques and the development of diagnostic molecular markers of endometriosis.

The current staging system for endometriosis: does it help?

A multicenter collaboration for data collection and statistical analysis may be necessary to establish and validate a classification system based on empirically derived scores for specific pathologic observations. The endometriosis pain instrument may be a tool for some of those variables with regard to pelvic pain. A similar strategy for uniform collection of data for analysis of important factors also is necessary for infertility. The challenge of creating a satisfactory classification of endometriosis remains. The ability of the current classification schemes to predict pregnancy outcome or aid in the management of pelvic pain is recognized to be inadequate. Further revisions of the current classification scheme are anticipated as the understanding of how endometriosis contributes to infertility and pelvic pain evolves. In any revision of the classification system, use of empirically derived weights and breakpoints to define disease stages based on outcome data in larger clinical trials should be attempted. It is also possible that additional factors, such as CA-125 level or lesion characteristics, may be shown to play an important role in prognosis. If so, these must be accounted for in the classification scheme. Careful and consistent use of the recommendations of the American Society for Reproductive Medicine classification of endometriosis subcommittee should allow for collection of data for use in further revisions. It is possible that a classification scheme that is designed to predict outcome with respect to pregnancy may be totally inadequate in assessing patients who have endometriosis and pelvic pain. Factors found to be important in the assessment of pelvic pain may be different from those involved with the pathophysiology of endometriosis and infertility. The AFS form suggested for use in the management of endometriosis in the presence of pelvic pain allows for recording of variables such as depth of invasion, histology, and documenting adjunct investigations and preoperative physical findings. Such prospective data collection and review in large centers may provide a large clinical base from which to derive empirical point scores and breakpoints in a classification scheme.

Transvaginal sonographic diagnosis of ovarian endometrioma

OBJECTIVE

To assess the efficacy of transvaginal sonography (TVS) in differentiating endometriomas from other adnexal masses.

METHODS

One thousand thirty-five adnexal masses undergoing laparoscopy or laparotomy were evaluated prospectively using TVS. Masses diagnosed as endometrioma according to their sonographic appearance were divided into two groups: those with a round shape, regular margins, thick walls and homogeneous, low-level echoes (group A); or those with irregular margins, internal septations and an anechoic appearance (group B).

RESULTS

The sensitivity of TVS in diagnosing endometriomas was 86.50% and the specificity 99.11%. The positive predictive value (PPV) and the negative predictive value of the test were calculated to be 91.45% and 98.14%, respectively. By using the criteria determining group A, the PPV of the test increased to 97%, whereas group B had a lower PPV (70.85%).

CONCLUSION

We propose that the accuracy of TVS in diagnosing endometriomas may be beneficial in various clinical conditions.

The potential value of magnetic resonance imaging in infertility

The potential value of magnetic resonance imaging as a diagnostic tool in infertility was investigated. Twenty-six women with primary or secondary infertility and symptoms of dysmenorrhoea or menorrhagia were studied prospectively using conventional T1- and T2-weighted spin-echo techniques. Positive diagnoses were obtained in 20 of 26 (76.9%) patients. Of these, 18 (69.2%) had lesions likely to be significantly contributing to infertility. Adenomyosis was detected in 14 patients (53.8%) with 11 showing the diffuse pattern while three had discrete adenomyomas. Cystic lesions typical of endometriosis were detected in seven patients (26.9%), four of these also had evidence of adenomyosis. The endometriotic lesions were also seen at laparoscopy in each case. Five patients (19.2%) had leiomyomas, one in a patient with adenomyosis and endometriosis and one in a patient with endometriosis alone. Only one patient had submucous leiomyomas causing significant distortion of the endometrial mucosa likely to affect fertility. Magnetic resonance imaging is valuable in the investigation of unexplained infertility where it provides a high diagnostic yield particularly if uterine pathology is suspected.

Scoring system for prediction of ovarian endometriosis based on transvaginal color and pulsed Doppler sonography

OBJECTIVE

To develop a new noninvasive scoring system using clinical signs and symptoms, CA-125 levels, sonographic findings, and transvaginal color and pulsed Doppler parameters for preoperative recognition of ovarian endometriosis.

DESIGN

A 5-year prospective study in patients undergoing laparotomy and laparoscopy.

SETTING

Department of Obstetrics and Gynecology, University of Zagreb, Sveti Duh Hospital, Zagreb, Croatia.

PATIENTS

Six hundred fifty-six benign and malignant adnexal masses, among which 103 were surgically proved to be ovarian endometriosis.

INTERVENTIONS

All patients undergoing laparotomy and laparoscopy were examined by transvaginal ultrasonography with color Doppler imaging. Serum levels of CA-125 were measured the day before surgery.

MAIN OUTCOME MEASURE

The total score was applied in all patients with adnexal masses.

RESULTS

The scoring system proved to be very useful in distinguishing ovarian endometriosis from other benign and malignant ovarian lesions, with a sensitivity of 99.02% and a specificity of 99.64%, compared with morphological scoring system's sensitivity of 83.91% and specificity of 97.12%.

CONCLUSION

The new noninvasive scoring system improves significantly the ability to discriminate between endometriosis and other benign and malignant ovarian entities.

The endoscopic localization of endometrial implants in the ovarian chocolate cyst

OBJECTIVE

To describe the characteristics of the endometrial cyst and to locate the implants for selective biopsy.

DESIGN

Prospective study.

SUBJECTS

Fifty-one women with one or two ovarian chocolate cysts of 3 cm or more were investigated.

INTERVENTIONS

Laparoscopy and random biopsy versus a new technique of ovarioscopy and selective biopsy.

MAIN OUTCOME MEASURE

Visual characteristics and histopathology of endometrial cysts.

RESULTS

The clinical suspicion of an endometrioma was confirmed in a series of 59 hemorrhagic cysts by histopathology in 89% and 42%, respectively, of typical and atypical cases and in 27% of recurrent chocolate cysts in the presence of postoperative adhesions. The atraumatic technique of ovarioscopy allowed description of the typical characteristics of the inner wall of the endometrioma and location of the active implants for biopsy. Endometrial tissue was obtained by small ovarioscopy-guided biopsies in 82% of the cases versus 42% in large random biopsies. Red lesions were highly significant for a mucosa-type implant and were predominantly located at the site of invagination stigma and adhesions with the pelvic wall.

CONCLUSIONS

Endoscopy of ovarian chocolate cysts allows observation of typical features of the wall that differentiates it from other benign cysts of the ovary. Microbiopsies obtained under endo-ovarian endoscopy provided significantly more active, endometrial tissue than random biopsies. The data confirm that in most cases the endometrioma is formed by invagination of the cortex and that active implants are located at the site of invagination. Ovarioscopy is therefore proposed as a useful tool to differentiate in doubtful cases between a hemorrhagic functional and an endometriotic cyst and to select the sites for biopsies.