Preoperative classification of endometriosis: a narrative review of revised American Society for Reproductive Medicine (r-ASRM), #Enzian, American Association of Gynecologic Laparoscopists (AAGL) 2021, and Numerical Multi-Scoring System of Endometriosis (NMS-E) systems.
Level 5 - mechanism / opinion, no new human data
Narrative literature review without systematic review methodology
PubMed 42211905 · doi:10.21037/gpm-25-3
What was done
The authors conducted a narrative literature review across PubMed, Embase, and Scopus (covering January 2015 to January 2025) comparing emerging preoperative classification systems for endometriosis (#Enzian, AAGL 2021, and NMS-E) against the intraoperative r-ASRM system. Out of initial search hits, they selected 17 articles for qualitative synthesis: 7 on #Enzian (3 original studies, 4 reviews), 5 on AAGL 2021 (2 original studies, 3 reviews), and 5 single-institution original studies on the NMS-E system.
What was found
The r-ASRM system is non-applicable preoperatively and correlates poorly with deep endometriosis. The #Enzian system allows imaging-based anatomical mapping but lacks composite severity scoring, pain evaluation, adhesion grading, and specific scoring for pouch of Douglas obliteration. The AAGL 2021 classification provides a surgical complexity score but lacks detailed assessment of pain, adhesions, and uterosacral ligament involvement. The NMS-E system integrates pelvic examination and ultrasound into an E-score (evaluating lesion, pain, and adhesion severity), with reported validation showing a strong correlation with surgical duration (r = 0.724, P < 0.01) and significantly better postoperative fertility outcomes in patients with lower adhesion scores (P < 0.05).
Why it matters
Standardizing preoperative endometriosis staging helps clinicians plan complex surgeries and counsel patients before laparoscopy, but existing scoring systems currently trade off anatomical precision, symptom capture, and ease of adoption.
Limits
This is a narrative review with selective study inclusion rather than a comprehensive systematic review. The evidence supporting the NMS-E system comes entirely from five studies conducted at the authors' own institution. No direct head-to-head prospective comparisons among all four systems were reported in the abstract.
Cited by
- supports The presence of an endometrioma (chocolate cyst) in an ovary categorizes a patient as approximately stage 3 out of 4 endometriosis.