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Stages of Endometriosis

by Tamer Seckin, MD | Posted on May 20, 2020

What are the stages of endometriosis?

Endometriosis is classified into four stages: I-minimal, II-mild, III-moderate, and IV-severe. Staging has been defined by the American Society for Reproductive Medicine (ASRM), with criteria based on the location of the disease, extent, depth of endometriosis implants, presence and size of ovarian endometriomas, and the presence and severity of adhesions.

StageAmerican Society of Reproductive Medicine Severity Classifications
Stage I Mild
Stage II Minimal
Stage III Moderate
Stage IV Severe

How are stages assigned?

The criteria that make up the stages of endometriosis are graded on a point system to determine classification. First developed in 1973, the classification scheme has been revised and refined three times for a more precise method of documentation. A score of 1-15 indicates minimal or mild endometriosis, while a score of 16 or higher indicates moderate to severe endometriosis.

What is the problem with this method of classification?

The scoring and stage of the disease are not indicative of pain level. Instead, this system was fundamentally developed as an indicator of endometriosis-associated infertility, and, therefore, has no specific correlation to any symptoms. This means that a woman in stage IV can be asymptomatic, while a stage 1 patient might be in debilitating pain.

Our Approach

What is the best way to obtain a thorough classification?

For an accurate diagnosis, it is necessary to conduct a direct visual inspection inside the pelvis and abdomen, as well as tissue biopsy of the implants. A pathologist will observe the obtained biopsy sample under a microscope in order to view any inflammatory changes or signs of cancer, which they will then report back to the surgeon. This ultimately allows your surgeon to gain a better understanding of the extent of your disease and thus provide a more descriptive classification of your particular case of endometriosis.

What are our “Descriptive Classifications of Endometriosis?”

Due to the factors mentioned above, your normal one through four classification of endometriosis may be of less significance than our descriptive classifications. We define four different forms of the disease that must be considered: peritoneal disease, ovarian endometrioma, deep infiltrating endometriosis (DIE) and frozen pelvis. Though different, they are not altogether clinically distinct, and the pathophysiological mechanisms involved in all four remain poorly understood.

Dr. Seckin’s Prefered ClassificationDescription
Early peritoneal
  • Infiltration of the lining of the abdomen (peritoneum)
Ovarian endometriomas
  • Large, fluid-filled "chocolate" cysts that form on, and even encapsulate, the ovaries
Cul-de-sac obliteration
  • Infiltration of the tissue lining the back wall of the uterus and rectum (cul-de-sac), an extension of the peritoneum
Deep infiltrating endometriosis (DIE)
  • Invasive endometriosis that penetrates the bladder and bowel wall
Frozen pelvis
  • In this rare condition, deep infiltrative lesions attach to pelvic ligaments, nerves, and muscle tissue. As a result, pelvic organs can be partially or entirely cemented

It is crucial to monitor and keep in mind the extent of your symptoms and the disease itself. Sometimes patients feel they need to mask their suffering, and it is incredibly disheartening and incorrect when their physician proceeds to tell them their pain is simply “emotional stress.” We believe that you deserve the care and attention that a complicated disease such as endometriosis deserves. This includes having honest discussions about the extent of symptoms you may be experiencing.

Ready for a Consultation?

Our endometriosis specialists are dedicated to providing patients with expert care. Whether you have been diagnosed or are looking to find a doctor, they are ready to help.

Our office is located on 872 Fifth Avenue New York, NY 10065.
You may call us at (646) 960-3080 or have your case reviewed by clicking here.



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