Endometriosis: surgical approaches to stages I and II

Abstract

© Cambridge University Press 2015. Introduction The most commonly used staging system for endometriosis is the revised American Society for Reproductive Medicine (ASRM) classification [1]. This requires calculation of a score based on the size of the endometriotic lesions, the depth of tissue involvement, and the presence and extent of adhesions around the fallopian tubes and ovaries as well as degree of pouch of Douglas (posterior cul-de-sac) obliteration. Patients are classified into one of four stages depending on the severity of disease: I (minimal), 1–5 points II (mild), 6–15 points III (moderate), 16–40 points IV (severe), >40 points. Stages I and II disease exclude any women with endometriomas larger than 1cm and complete cul-de-sac obliteration. Stage I endometriosis usually affects the peritoneum superficially, with filmy adhesions that enclose one-third or less of the tubes or ovaries. Stage II is more advanced disease with more extensive superficial peritoneal lesions and filmy adhesions around the fallopian tubes and ovaries. In stage II, the adhesions may be denser and enclose up to two-thirds of the ovary. Stage II endometriosis may also include the presence of a small endometrioma ≤1cm in diameter in the ovary. The ASRM classification puts the deeply infiltrating endometriosis without cul-de-sac obliteration, endometriomas, and significant peritubo-ovarian adhesions into the mild endometriosis category. However, this type of endometriosis may have wider clinical implications on symptomatology and its surgical treatment tends to be more challenging. The ASRM classification is based on the morphological appearance at the time of surgery and the terms “minimal” and “mild” do not correlate with the clinical impact of the disease. So, despite the seemingly mild presentation, early-stage disease is not innocuous and can be associated with significant pain and impaired fertility. Moreover advancing morphological stage of endometriosis does not correlate well with deteriorating symptoms. So it is possible for surgeons to come across minimal or mild endometriosis in women without any clinical symptoms. Surgeons then find themselves in a dilemma over whether they should treat or not.