4 Stages of Endometriosis and What They Can Mean

These stages can classify endometriosis. But they don’t always tell a complete story about your symptoms and quality of life.

Endometriosis is a medical condition characterized by the presence of cells resembling the endometrium, the tissue lining the interior of the uterus, growing outside of their normal location within the uterus. These aberrant cells, referred to as endometrial cells, can give rise to lesions that might undergo shedding, inflammation, or lead to the formation of cysts and scar tissue. Consequently, individuals afflicted by endometriosis often experience distressing symptoms, including intense menstrual bleeding and other forms of discomfort.

While the typical sites of endometriosis development encompass the uterine surface, the pelvic floor, fallopian tubes, and ovaries, these lesions can also extend their reach to involve the intestines and rectum.

Medical practitioners employ a staging system to classify the severity of the condition, based on factors such as lesion location, dimensions, and depth. One of the widely adopted staging systems, as outlined by the American Society of Reproductive Medicine (ASRM), encompasses four distinct stages. Gaining insight into your specific stage of endometriosis aids in devising a tailored treatment strategy.

This article delves into the ASRM’s staging framework and delves into alternative staging systems that healthcare professionals might employ to delineate and elucidate the nature of endometriosis.

The ASRM Stages of Endometriosis

The American Society of Reproductive Medicine (ASRM) offers a comprehensive booklet detailing the intricacies of endometriosis and its corresponding staging procedure. This resource not only elucidates the condition itself but also furnishes a concise explanation of essential terminology, along with a breakdown of each stage, spanning from I to IV. Nevertheless, delving into the nuances of the staging system requires acknowledging its inherent limitations.

Key Terms Involved in the I–IV Staging System

The ASRM provides distinct definitions for the following terms:

1. Endometriosis Implants: These are instances where endometrial cells, which conventionally flourish within the uterine confines, proliferate and extend beyond the uterus. These endometrial lesions generally assume a small and flat structure.

2. Endometrial Adhesions: These involve accumulations of fibrous tissue that congregate in bands. Such adhesions possess the potential to bind organs together, commonly affecting abdominal and pelvic organs. A study featured in the 2019 edition of the International Journal of Fertility and Sterility expounded on the origin of endometrial adhesions, attributing their formation to an underlying inflammatory process.

3. Ovarian Endometriomas: Also recognized as “chocolate cysts,” these cysts harbor blood-filled content that evolves in color over time to a brownish hue. These cysts manifest as a result of the growth and dispersion of endometrial cells onto the ovaries.

Four Stages of Endometriosis

As outlined by the ASRM, the I–IV staging system is structured as a point-based framework. The classification of endometriosis into these stages hinges on several criteria, including:

1. Implants Location, Extent, and Depth: The presence, scope, and depth of endometrial implants outside the uterus.

2. Adhesions Presence and Severity: The extent and seriousness of adhesions, whether they are filmy and thin or dense in nature.

3. Ovarian Endometriomas: The existence and size of ovarian endometriomas, commonly referred to as “chocolate cysts.”

Medical practitioners assign points for each category, with higher point values correlating to more advanced stages of the condition. An article featured in Cureus in 2018 delves into the specific point ranges associated with each stage.

Stage I: Recognized as minimal endometriosis, this stage entails superficial implants and mild adhesions situated outside the uterus. The point range for minimal endometriosis is between one to five.

Stage II: Termed mild endometriosis, this stage encompasses implants that can be either superficial or deep, accompanied by mild adhesions. The extent of endometriosis may be relatively widespread in this stage, potentially including the presence of deep implants. The point range for mild endometriosis is six to 15.

Stage III: Designated as moderate endometriosis, this stage involves the presence of deep implants and denser adhesions compared to Stage II. Consequently, endometriosis tends to be more widespread than in the previous stage. The point range for moderate endometriosis falls between 16 to 40.

Stage IV: Referred to as severe endometriosis, this stage encompasses the presence of deep implants and substantial adhesions. While there might still be instances of superficial endometriosis and filmy adhesions, the overall extent of the disease surpasses that observed in Stage III. A point score greater than 40 signifies severe endometriosis.

Limitations of the ASRM Endometriosis Staging System

The progressive nature of the ASRM staging system may suggest a sequence where endometriosis initiates in one anatomical region before extending to more distant organs. Nonetheless, it’s important to acknowledge that endometriosis can also manifest as a widespread condition right from its outset, according to insights provided by Hugh Taylor, MD, Vice President of the ASRM, as conveyed to Health.

Hugh Taylor, MD, articulated, “When evaluating treatment outcomes or comparing different surgical interventions, it becomes imperative to establish a systematic and quantitative means of comparison. However, it’s crucial to note that this staging system differs significantly from those with prognostic implications, as observed in the context of cancer.”

Furthermore, the four-stage classification doesn’t necessarily align with factors such as infertility or pelvic pain severity experienced by individuals. Consequently, although identifying the stage remains instrumental in shaping treatment strategies, it is by no means the sole determinant.

Dr. Taylor emphasized, “Patients often seek to comprehend the extent of endometriosis spread, but it’s worth noting that an individual with minimal to mild endometriosis might experience more pronounced pain than someone with severe endometriosis.” In a similar vein, he pointed out that an individual classified under stage 1 might face more formidable fertility challenges than someone placed in stage 4.

Endometriosis Diagnosis

Laparoscopy stands as the sole definitive method for confirming the presence of endometriosis. Beyond confirmation, this procedure also enables healthcare practitioners to gauge the extent of endometriosis and assign it a corresponding stage.

In the course of laparoscopy, a healthcare professional creates small incisions in the pelvic region and subsequently introduces a diminutive device termed a laparoscope. This instrument is equipped with a miniature camera at its tip, affording the healthcare provider a visual examination of any endometrial implants or adhesions. Notably, this procedure also facilitates the collection of tissue samples for biopsy.

Additionally, during the laparoscopy, the healthcare provider may assess fertility by evaluating the openness of the fallopian tubes. This is achieved through the introduction of a specialized dye, which is then tracked to determine if it successfully traverses the fallopian tubes.

How To Treat Endometriosis

Treatment approaches for endometriosis are tailored based on individual symptoms and reproductive objectives. Among the prevalent treatment options for endometriosis are:

1. Laparoscopy: Beyond its diagnostic role, laparoscopy can effectively address endometriosis by excising lesions, scar tissue, and cysts. This surgical intervention holds the potential to alleviate pain and safeguard fertility. However, it’s important to note that symptoms often resurface within a few years post-surgery.

2. Hormonal Birth Control: Hormonal birth control methods, including pills, patches, and vaginal rings, offer relief from distressing menstrual bleeding. By leveraging a combination of estrogen and progesterone hormones, these methods exert control over or even halt the menstrual cycle.

3. Gonadotropin-Releasing Hormone (GnRH) Agonists: Designed to obstruct estrogen production, GnRH agonists effectively suspend the menstrual cycle. However, it’s worth noting that these medications frequently entail adverse side effects akin to menopausal symptoms.

4. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Over-the-counter medications like ibuprofen (Advil) can effectively mitigate pain associated with endometriosis.

5. Fertility Treatments: Endometrial lesions can potentially disrupt the anatomical integrity of reproductive organs, notably the fallopian tubes, complicating conception. In scenarios where infertility takes precedence, fertility treatments such as in vitro fertilization (IVF) might represent the optimal avenue to pursue.

Ultimately, the choice of treatment hinges on a comprehensive evaluation of individual circumstances, ensuring that the selected approach aligns with symptom relief and reproductive aspirations.

Other Methods of Staging Endometriosis

Researchers have explored alternative approaches to categorize endometriosis, taking into account the prominence of painful symptoms. One noteworthy instance is a study featured in the 2017 edition of Human Reproduction, wherein researchers emphasized the necessity for a comprehensive international agreement on the classification of endometriosis. The focal point of their argument was that the staging of endometriosis should be informed by the perspectives and experiences of individuals grappling with the condition.

ENZIAN Scale

A study published in 2020 within the realm of Global Reproductive Health introduced the ENZIAN scale, a classification framework that takes into consideration the manifestation of painful symptoms. The ENZIAN scale is structured around eight distinct “compartments,” each corresponding to specific locations where endometrial lesions may be found. These compartments encompass:

1. Compartment A (vagina, rectovaginal septum)

2. Compartment B (uterosacral ligaments, parametrium)

3. Compartment C (rectum, sigmoid colon)

4. Compartment FA (adenomyosis)

5. Compartment FB (urinary bladder)

6. Compartment FU (intrinsic involvement of the ureters)

7. Compartment FI (intestine)

8. Compartment FO (other localizations)

Incorporating an additional layer of complexity, the ENZIAN scale also incorporates an evaluation of lesion severity and size. Lesions are categorized into one of the following grades based on their dimensions:

• Grade 1: Lesions less than one centimeter
• Grade 2: Lesions between one to three centimeters
• Grade 3: Lesions greater than three centimeters

The researchers behind this study proposed that the ENZIAN scale potentially offers a means to establish a connection between experienced pain and the intensity of symptoms. For instance, a classification of A1 signifies endometrial involvement within the vagina and rectovaginal septum, accompanied by lesions measuring less than one centimeter.

Notably, the researchers advocated for healthcare practitioners to combine the utilization of the ENZIAN scale with the ASRM’s established staging system. This dual approach was suggested as a means to enhance diagnostic precision and clarity.

Descriptive Classifications of Endometriosis

Tamer Seckin, MD, an esteemed gynecologist, laparoscopic surgeon, and expert in endometriosis, presents an alternative method for staging endometriosis through descriptive classifications. These classifications, determined by the location and severity of lesions, encompass:

1. Peritoneal Endometriosis: This classification pertains to lesions that develop on the peritoneum, a protective membrane lining the abdominal cavity.

2. Ovarian Endometriomas: In this context, endometriomas emerge within the ovaries, and they have the potential to rupture, disseminating lesions to neighboring organs.

3. Cul-de-Sac Obliteration: This descriptor signifies endometriosis extending its reach to infiltrate pelvic organs. Commonly, cul-de-sac obliteration affects the rectum and the exterior of the uterus.

4. Deep Infiltrating Endometriosis: This designation reflects a higher level of invasiveness. Lesions associated with deep infiltrating endometriosis penetrate other organs, including the bladder or the wall of the bowel.

5. Frozen Pelvis: In this scenario, lesions deeply infiltrate pelvic ligaments, nerves, and muscular tissues, potentially leading to neighboring organs becoming immobile or “frozen.”

Tamer Seckin’s approach offers a comprehensive framework that takes into account both the anatomical location and the extent of the disease, thereby providing a nuanced understanding of endometriosis progression and severity.

Delays in Endometriosis Diagnosis

The journey to diagnosing endometriosis can be plagued by prolonged delays, with an average span of nearly seven years before confirmation is obtained. Such diagnostic procrastination results in postponed treatment opportunities and needless suffering.

Several underlying factors contribute to these diagnostic delays, including:

1. Misinterpretation of Symptoms: Certain symptoms, such as painful menstrual cycles, are frequently misconstrued as typical, thereby impeding swift recognition of endometriosis.

2. Reluctance to Discuss Reproductive Health: Discomfort or embarrassment linked to discussing reproductive health matters with healthcare professionals can hinder open conversations that lead to accurate diagnoses.

3. Toleration of Symptoms: Some individuals endure discomfort without seeking medical attention, possibly underestimating the seriousness of their symptoms.

A hallmark indicator of endometriosis is pelvic pain, which may manifest beyond the menstrual period for some individuals. While others might experience intense cramping during their menstrual cycles, sufficiently debilitating to disrupt their daily routines, these painful periods often get dismissed as “normal.”

Dr. Taylor emphasized, “A common refrain I hear from endometriosis patients is their initial struggle with pain, often met with responses from family, friends, and even healthcare providers that downplay it as a regular part of menstruation. Only when the pain escalates to the point of causing disruptions, like missing school or work, does the severity gain recognition.”

Efforts to expedite endometriosis diagnosis and treatment may involve clinical identification of signs that obviate the need for immediate surgery, according to Dr. Taylor.

While laparoscopy remains the gold standard for diagnosing endometriosis, other diagnostic avenues can offer insights into the condition’s likelihood. For instance, a pelvic examination might reveal significant cysts or scar tissue situated behind the uterus. Imaging modalities such as ultrasound or magnetic resonance imaging (MRI) can also be employed to detect cysts.

Dr. Taylor underscored that taking a person’s pain seriously can potentially save years of erroneous diagnoses, expediting the route to a correct identification. Early diagnosis and treatment can not only alleviate symptoms more promptly but also mitigate the impact of pain and debilitating scar tissue.

A Quick Review

Multiple staging methods exist for categorizing endometriosis. Among these, the ASRM’s four-stage scale stands as one of the widely employed frameworks for classifying the condition. However, researchers underscore the significance of factoring in painful symptoms and the impact on one’s quality of life.

For individuals who harbor concerns about endometriosis, advocating for oneself and proactively engaging with a healthcare provider are pivotal steps toward safeguarding personal health and well-being.