Endometriosis Concepts

Endometriosis Concepts covers endometriosis and infertility. The site is maintaned by Dr. Dan Martin and includes:

IntroductionConcepts and TheoriesEndometriosis Fertility IndexIs there a Stage 5?

Additional information is at:

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Introduction

Studying endometriosis is like nailing Jell-O to a tree.

Donna Vogel, National Institutes of Health 2000

Clinical descriptions suggesting the presence of endometriosis were first written almost 4,000 years ago (Redwine 2012, Nezhat 2012). But a microscopic description did not occur until 1860 when Rokitansky described the histologic characteristics of large nodules of deep, infiltrating endometriosis. Russell (1899) subsequently discovered smaller, unseen, microscopic, ovarian endometriosis.

Sampson was the first to use the term endometriosis. He published a series of articles from 1921 to 1940 in which he described lesions including chocolate cysts, blebs, adenomyomatous infiltration, adherent surfaces, red raspberries, purple raspberries, blueberries, deep infiltration, inflammatory reactions, cancer arising in endometriotic implants and peritoneal pockets. He discussed that endometriosis was different than endometrium "both in structure and in function" and that both could coexist in one patient with recognizable transition. Sampson concluded that retrograde flow does not explain all endometriosis and suggested additional theories, such as celomic metaplasia or venous dissemination.

Many of the anatomic phenotypes that Sampson described are contaned in:

Fallon (1950) added to our understanding with clarification of colorless, amenorrheic lesions while Karnaky (1969) published an age dependent appearance of endometriosis starting with an initial water blister appearance.

Goldstein (1980) found petechial-like endometriosis and blebs in adolescents with chronic pain. Jansen (1986) subsequently confirmed Sampson's, Karnaky's, and Goldstein's finding with six different descriptions and also noted an additional six look-a-like lesions that were not endometriosis. Redwine (1988) then added the more descriptive term “near-contact laparoscopy” to update Goldstein’s “close-up view.”

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Concepts and Theories

Of the more than 180 concepts and theories since 1855 BC covered in "Concepts and Theories," it generally takes fifteen to discuss what I saw or published and many more to introduce what I have read.

"Concepts and Theories”


is periodically updated and can be downloaded at:

An endometriosis concept or theory may be useful in guiding research, explaining treatment, acting as a framework for education, and studying endometriosis. However, no concept or theory is completely adequate or determines if a treatment works. Treatment should be based on evidence of success and updated as knowledge changes.

Theories are divided into the Cell of Origin, Dissemination / Metastasis, and the pathophysiological Transition from an original endometrial or precursor cell to endometriosis.

Cell of Origin

  • Endometrium (Müllerian)
  • Embryonic Müllerian Remnants
  • Non-Müllerian Stem Cells

Dissemination (Metastasis)

  • Retrograde Menstruation
  • Hematogenous Dissemination
  • Lymphatic Dissemination
  • Traumatic / Surgical Dissemination
  • Abnormal Fetal Müllerian Positions
Transition

The transition from a cell of origin to deep infiltrating endometriosis holds the most promise for research and development of therapeutic options. Transition involves the local environment, inflammation, epigenetic changes, genetic changes, biochemical changes, immunologic changes, apoptosis, autophagy, fibrosis, muscular metaplasia, cancer-associated driver mutations, angiogenesis, genetic dysregulation and more that are covered in "Concepts and Theories." The second link is for viewing on a mobile device.

Concepts and Theories

Mobile Version

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Endometriosis Fertility Index

David Adamson's Endometriosis Fertility Index (EFI) is a clinical tool used to predict pregnancy rates after endometriosis surgery. It is the only system that is predictive of fertility, but is not a staging system. The EFI has 6 levels and is based 50% on history, 30% on surgical findings at the completion of surgery, and 20% on the American Fertility Society (rAFS) total and endometriosis sub-total scores.

The 1984 rAFS staging system was renamed the revised American Society of Reproductive Medicine (rASRM) staging system in 1996 after that organization changed their name. The rASRM endometriosis staging system is otherwise the same as the rAFS endometriosis staging system.

The rAFS is the staging system most commonly used at surgery but is not predictive of fertility. It can be used to describe the appearance at surgery and is somewhat predictive of surgical difficulty. The rAFS has 150 points. A score 40 or higher is rAFS stage 4. The rAFS separates stage 4 into scores for 4A (40 to 70 points) and 4B (71 to 150 points). Scores of 71 and higher are generally seen with severe adhesions. Adhesions are a type of scar tissue that can block the pathway that eggs use to get from the ovary to the tube.

Click for EFI Calculator

Adamson GD & Pasta DJ. Endometriosis fertility index: the new, validated endometriosis staging system. Fertil Steril 2010;94(5):1609–15

American Fertility Society. Revised American Fertility Society classification of endometriosis 1985. Fertil Steril 43(3):351-352, 1985

American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril 67(5): 817-21, 1997

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Is there a stage 5 endometriosis?

Michel Canis (1992) suggested using a revised American Fertility Society (rAFS, 1985) score of >70 as a new stage 5 for endometriosis.

This is also the 4B sub-score of the Endometriosis Fertility Index (EFI) (Adamson 2010). The EFI is a clinical tool used to predict pregnancy rates after endometriosis surgery. It is the only system that is predictive of fertility, but is not a staging system. The EFI has 6 levels and uses the 1985 rAFS staging system’s total and endometriosis sub-total score separately.

The rAFS (or rASRM) is the staging system most commonly used in surgical research. It is useful in comparing the gross appearance at the beginning of surgery and is somewhat predictive of surgical difficulty. But, it is not predictive of fertility, pain, the depth of infiltration, or the volume of infiltrating endometriosis.

The rAFS has 150 points. A score of 40 or higher is rASRM stage 4. The EFI separates stage 4 into scores for 4A (40 to 70 points) and 4B (71 to 150 points). Scores of 71 and higher are generally seen only with severe adhesions. Adhesions, a type of scar tissue, can block the pathway that the eggs use to get to the tube.

Adamson GD & Pasta DJ. Endometriosis fertility index: the new, validated endometriosis staging system. Fertil Steril 2010;94(5):1609–15

American Fertility Society. Revised American Fertility Society classification of endometriosis 1985. Fertil Steril 43(3):351-352, 1985

American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril 67(5): 817-21, 1997

Canis M, Pouly JL, Wattiez A, et al. Incidence of bilateral adnexal disease in severe endometriosis (revised American Fertility Society [AFS], stage IV): should a stage V be included in the AFS classification? Fertil Steril 1992;57:691–692.

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Updated December 6, 2018