Dr Andrew Cook: Hi guys, good morning, Dr.Cook. Today we’re going to talk about classification of endometriosis. I get a lot of questions asking “what stage is my endometriosis?” This is the ASRM, American Society for Reproductive Medicine classification system, and what I am going to show you, some high-tech video features here. This will be on the website also. This is the worksheet for endometriosis classification, and you can see we have stage 1, 2, 3, and 4. It’s a point system -- the maximum number of points allowable is 150 so you can see stage 1 is 1-5, stage 2, 6-15, and stage 3, is 16 and above. Now, there are three basic categories, we have endometriosis in this upper dark box, adhesions or scar tissue is all down below and then there is the posterior cul-de-sac, so let’s go through it one section at a time.
I’ve often said that if it’s not in the ovary deep an endometrioma chocolate cyst, it cannot be any more than stage 2 and the reason is we have peritoneum for endometriosis and ovary, so there are two basic locations we are looking for endometriosis. Peritoneum can be superficial or deep and if we go over into each of these columns less than one centimeter, which is about 3/8 of an inch, 1-3cm. 3cm is a little over an inch and greater than 3cm. So if it’s all over the peritoneum, the peritoneum is the inside lining of the pelvis, if it all over the peritoneum and superficial it’s 4 points. So you only get 4 points if it’s just on the surface of the peritoneum.
If it’s deep, in other words, it goes a little bit deeper than the surface of the peritoneum, 6 points so that barely gets you to Stage 2. So again if you don’t have any scar tissue, don’t have endo in the ovaries, the most you can be is a 1 or 2, and we all know stage 1 or 2 can be more painful than a stage 3 or 4. Now for the ovary, superficial endometriosis on the surface of the ovary or deep an endometrioma, less than one centimeter 1-3 and greater than 3, so greater than 3 you get 20 points right there so if you have an endometrioma in 1 ovary and that’s it you are stage 3. So you have the right and the left. So for endometriosis, you can get a maximum of 46 points. That’s it, so yes you could get into stage 4 with that.
The posterior cul-de-sac, the area behind the uterus and the bowel, partial so you know it’s almost like a zipper so the bowel starts to scar to the back of the uterus and that’s obliteration of the cul-de-sac. Complete obliteration right there you get 40 points, right there you are stage 4.
Okay then we have adhesions and remember this was made to try to predict the chance of getting pregnant after surgery not the degree of pain and we know it does not do that. That’s what the EFI or Endometriosis Fertility Index is about. Ok adhesions/scar tissue, two areas, the ovary or Fallopian tube. You have filmy, which is kinda like spider webs, you know just thin stuff, dense, things are glued together so then it’s less than ⅓ enclosure ⅓-⅔ and greater than a ⅔ enclosure. So you can get a total of 4 points if your ovary has filmy adhesions all around it, if it’s encased in adhesions then that’s 16. So each right and left ovary scar tissue, Fallopian tube, right and left Fallopian tube, so you can see really we have the numbering -- it depends on how much endometriosis you have but if it’s all over inside, you really are a stage 1, maybe a stage 2. That’s where they were trying to guess at the time what affects fertility and the thinking was if the ovaries or tubes are affected by endometriosis or scar tissue then it’s bad. So invasive endometriosis really stage 3 and 4, noninvasive stage 1 or 2.
So hopefully that helps, but I think part of what I want to do is educate you guys on how to do the staging, what is a proper diagnostic laparoscopy. And again we all know right now a lot of patients know more than their doctor, but let’s get the correct information so you guys are informed, smart consumers. And that’s how we are going to change the way endometriosis is treated altogether. Alrighty, have a great weekend talk to you later!