Types, Severity and Classification of endometriosis – adenomyosis

The endometrium is the tissue lining the inside of the uterus. The endometrium grows during the cycle and is shedded at menstruation.
Endometriosis : is by definition endometrial stroma and glands outside the uterus
Adenomyosis : endometrial stroma and glands in the myometrium of the uterus

Microscopy and activity of endometriosis.

endo deep morph1 Types of endometriosis
deep endometriosis
endo deep morph2 Types of endometriosis
is very active

Subtle endometriosis is morphologically very active
Typical endometriosis are burnth out lesions
Cystic ovarian endometriosis contains hardly any endometriotic cells in the wall.
Deep lesions are morphologically very active

The activity of endometriosis is sometimes used as argument to consider subtle endometriosis as ‘severe’ since active ; For this read the discussion on the pathophysiology

Clinical types of endometriosis

Clinically endometriosis varies from tiny little endometriosis to large chocolate cysts or invasive endometriosis. It is unclear whether subtle, typical, cystic, and deep endometriosis are 1 or several diseases

Subtle endometriosis : 1-3 mm superficial

 Types of endometriosis
white vesicle
endo gen polipoid2 Types of endometriosis
polipoid lesion

Believed to be the early stages after implantation : these are small endometriosis (1 to 3 mm) which macroscopically look like white vesicles, red vesicles, or flame like endometriosis.

Subtle endometriosis can hide more severe deep endometriosis and are often associated with typical endometriosis. In the example below, subtle endometriosis are shown covering a deep endometriotic lesion whereas a typical endometriosis is visible in the left uterosacral ligament.
Subtle lesion are not a pathology and occur in 80% of a normal population. Subtle endometriosis can present very atypically and even mimic an ovarian cancer as shown below right. Another frequent mistake is to diagnose ‘endosalpingiose’ as endometriosis


endo deep atyp1 Types of endometriosis
endo deep atyp2 Types of endometriosis
endo deep atyp3 Types of endometriosis
endo gen polpoid Types of endometriosis


endo endosalpingiosis en Types of endometriosis
endo tuba orig Types of endometriosis
red vesicle
endo subtle5 en Types of endometriosis
white vesicle
endo subtle orig Types of endometriosis
white vesicle


Typical endometriosis : 0.5-4 cm superficial lesions

endo typ it Types of endometriosis
typical lesion bladder
endo gen diaphragm Types of endometriosis

Typical endometriosis are black puckered endometriosis generally in a white sclerotic area. They are 1 to 2 cm in diameter, but can cover much larger area’s. These endometriosis are found not only in the pelvis but also on the diaphragm.

Deep endometriosis often present as typical endometriosis.

Typical endometriosis can present atypically.

The recognition of subtle endometriosis was an historical mistake : indeed by pathology this fitted the definition of 1900 ‘endometrial glands and stroma outside the uterus’. Yet including subtle in mild endometriosis all women had endometriosis. It became debated in the early nineties but it took until 1999 when

Koninckx et all described the endometriotic disease theory to dismiss subtle endometriosis as a pathology.


endo gen typical2 Types of endometriosis
endo gen typical3 Types of endometriosis
endo gen typical4 deep Types of endometriosis
endo gen typical1 Types of endometriosis


endo typ atyp5 Types of endometriosis
endo typ white it Types of endometriosis
endo typ atyp3 Types of endometriosis
 Types of endometriosis


Cystic ovarian endometriosis

stripping Types of endometriosis
Stripping of cyst
0312verbaenen 710506v397 4 Types of endometriosis
can mimic ovarian cancer
endo gen eoma Types of endometriosis

Cystic ovarian endometriosis are Chocolate cysts the ovary. These cysts are mostly 3-4 cm in diameter but can grow as large as 15 cm.
These cyst usually form adhesions with the pelvic wall and the other organs of the pelvis.
As a therapy stripping of the wall is the preferred technique. Medical therapy is ineffective
A cystic corpus luteum can mimic a cystic ovarian endometriosis


endo endometrioma 1 Types of endometriosis
small cyst
endo endometrioma 2 Types of endometriosis
laser incision
endo endometrioma 5 Types of endometriosis
endo endometrioma 6 Types of endometriosis
closure with glue


Deep endometriosis : solid tumors

endo surgery deep rectovag Types of endometriosis
Recto-vaginal nodule
endo gen deep2 Types of endometriosis
deep after surgery
endo gen deep1 Types of endometriosis
before surgery


Endometriosis can present as solid tumors up to 5 by 6 cm in diameter most frequently in the pouch of Douglas.
From the left picture it is obvious that this endometriosis is in close proximity of the vaginal wall (hence dyspareunia) and of the rectum (hence pain during bowel movement).
Other localizations are the sigmoid (not detectable clinically and easily missed during laparoscopy (except when the surgeon has great experience)and between the uterus and the bladder (hence bladder irritation and pain.


Images ofRectovaginal nodules : Type I II III

endo deep frequency Types of endometriosis
diameter of nodules
endo deep diagnosis2 Types of endometriosis
only the bigger are felt
endo deep localisation Types of endometriosis
our surgeries
0411 deep1 Types of endometriosis
central nodule


0411 deep1 Types of endometriosis
bowel hides deep
endo deep en Types of endometriosis
rectoscopy nl Types of endometriosis
normal rectoscopy
rectoscopy eose Types of endometriosis
partial occlusion


Endometriosis can involve the vesico-uterine fold

endo deep bladder1 Types of endometriosis
vesico-uterine fold
endo deep vesicout1 Types of endometriosis
endo deep vesicvanroy 1 Types of endometriosis
blue spots at cystoscopy
endo deep vesicout4 Types of endometriosis
hidden nodule


Endometriosis can involve the ureter and the vagina

endo deep diagnosis tv2 Types of endometriosis
ureter involvement
endo deep hydronef Types of endometriosis
endo deep vagin it Types of endometriosis
vaginally visible
endo deep vagin2 it Types of endometriosis
after excision


Endometriosis can also be found at the level of the sigmoid : unless looked for this endometriosis are missed at laparoscopy since situated higher outside the pelvis, as shown on the left image

endo deep sigmoid Types of endometriosis
sigmoid nodule
endo rectosigmoid1 Types of endometriosis
contrast enema to judge occlusion
endo rectosigmoid2 Types of endometriosis
50% occlusion
endo rectosigmoid2 Types of endometriosis
50% occlusion


The Ovarian remnant Syndrome

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endo ovarian remnant1 Types of endometriosis

The ovarian remnant syndrome is fortunately rare. The literature is almost empty and I have not seen more than ten over the last 15 years. Diagnosis and surgery always are difficult.
The ovarian remnant syndrome should be thought of when a women following hysterectomy and ovariectomy has severe chronic pain, whereas at ultrasound (or other imaging techniques, a multicystic ovary is found with a suspicion of endometriosis). At laparoscopy as depicted below, almost invariably a frozen pelvis with encapsulated ovary is found : at dissection after identification of the ureter, is becomes immediately clear that the ureter is located inside the ovarian mass. Therefore the surgeon should be very experienced.


endo ovarian remnant2 Types of endometriosis
endo ovarian remnant4 Types of endometriosis
shows ureter
endo ovarian remnant5 Types of endometriosis
through the lesion
endo ovarian remnant6 Types of endometriosis
after resection


endo adenomyosis MRI nl Types of endometriosis
Nl Junctional zone
09 adenomyosis2 Types of endometriosis
Thickened Junctional zone
adenomyosis nodule Types of endometriosis
focal andenomyosis
adenomyosis transmural Types of endometriosis
Transmural adenomyose
endo adenomyosis1 Types of endometriosis
Transmural adenomyose
070428brazil adenomyosis Types of endometriosis

There is a lot of confusion
The definition is clear: stroma and glands in the myometrium. This is however a diagnosis by pathology made after hysterectomy.
The prevalence vaies between 30 and 70% according to the number of slides invesigated .
The diagnosis can be also tentatively made with imaging as ultrasound or MRI. Two types can be diagnosed : junctional zone thickening and focal adenomyosis. The biggest problem is that often diagnosis is only 70% accurate.
Adenomyosis ss believed to be a cause of pain and infertility with little evidence
Adenomyosis is often an alibi to do an hysterectomy in women with chronic pain since theoretically adenomyosis is difficult to exlude


Peritoneal Pockets or Allen en Master syndrome

endo allen it Types of endometriosis
Allen en Masters
 Types of endometriosis
Allen en Masters
100310 allenmasters1 Types of endometriosis
Allen en Masters
100310 allenmasters3 Types of endometriosis
Allen en Masters


Peritoneal pockets are an unclear pathology Pockets in the peritoneum. They can be large and deep. Peritoneal pockets are believed to be associated with endometriosis
Excision is believed to be the right therapy. (click for images of surgery )


Haemorrhagic ascites

art ascites Types of endometriosis

Endometriosis associated with haemorrhagic ascites is a rare condition. Can contain up to 6-10 liters and Is Believed to be similar to a Meigs syndrome

What is severe endometriosis – which classifications ??

endo deep classif Types of endometriosis
History of classifications
1980 Acosta classification made a distinction between superficial and cystic ovarian endometriosis.
1985 AFS classificationA point scoring system. Essentiall I and II were superficial endometriosis, whereas III and IV cystic ovarian with adhesions.
1986 Subtle were described after this many women which beforehand were classified as ‘normal’ now became endometriotic.
1989 Deep was described

The definition of severe has become variable according to the authors
Severe = big endometriosis subtle are very small, typical generally small, cystic can be large cysts with a lot of adhesions, whereas deep can cause a lot of pain and are surgically the most challenging. Obviously a nodular lesion of 0.5 cm diameter and of 5 cm diameter is not the same.
severe = active endometriosis.By pathology subtle and deep are active endometriosis, whereas typical and cystic are generally inactive.
Severe=Surgically difficult

the rAFS Classification is a surgical classification without subtle and deep The rAFS is the most widely used classification. It is a point scoring system for diameter of endometriosis and for adhesions. It is an old surgical classification. Deep endometriosis are not represented : a most severe deep lesion of 5 cm can be calssified as I.Classes I and II are superficial endometriosis (thus subtle or typical) of respectively less or more than 3 cm in diameter.-classes III and IV represent cystic ovarian endometriosis with adhesions.
The Leuven – AFS classification. adds subtle and deep endometriosis to the rAFS