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Types, Severity and Classification of endometriosis - adenomyosis


Microscopy and activity of endometriosis.

Subtle endometriosis is morphologically very active
Typical endometriosis are inactive burnt out lesions
Cystic ovarian endometriosis is inactive and 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

Deep endometriosis mophology

Deep endometriosis

Deep endometriosis

Deep endometriosis is active

Clinical types of endometriosis

Subtle endometriosis : small superficial endometriosis

Subtle endometriosis are believed to be the early stages after implantation. They are small lesions (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

Typical endometriosis : 0.5-4 cm superficial lesions

p>Typical endometriosis are black puckered endometriosis generally in a white sclerotic area. They are 1 to 2 cm in diameter, or larger. These endometriosis are found in the pelvis and on the diaphragm.

Deep endometriosis often present as typical endometriosis.

Typical endometriosis can present atypically.

Often the mistake is made to consider subtle endometriosis as disease Koninckx et all described the endometriotic disease theory to dismiss subtle endometriosis as a pathology.

Cystic ovarian 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

Deep endometriosis : solid tumors

Endometriosis can present as solid tumours 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, causing dyspareunia, and of the rectum, causing 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.

Deep endometriosis of the rectovaginal septum

rectoscopy is generally normal ; only the larger ones are felt

Deep endometriosis of the vesico-uterine fold  and the ureter

Deep endometriosis of the sigmoid

is easily missed during laparoscopy and is generally underestimated ; it is  difficult surgery.

Fot this reason we think that a contrast enema remains the only reliable method to judge occlusion


The definition is clear: endometrial stroma and glands in the myometrium. The prevalence varies between 30 and 70% according to the number of microscopical slides investigated .
There are 3 types of adenomyosis

  • thickening of the junctional zone
  • diffuse adenomyosis
  • nodular adenomyosis

Adenomyosis is a cause of pain and infertility

For a full discussion of adenomyosis read our recent article below


click to read full article

The Ovarian remnant Syndrome : 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 multi-cystic 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.

Peritoneal Pockets or Allen en Master syndrome : endometriosis

Peritoneal pockets are an unclear pathology and generally contain endometriosis at the bottom.

They can be large and deep.

Superficial excision is believed to be the right therapy.

Haemorrhagic ascites Endometriosis

Endometriosis associated with haemorrhagic ascites is a rare condition and the abdomen can contain 6-10 litres. We believe as published the mechanism is similar to a Meighs syndrome 2008_ussia_ascites

What is called severe endometriosis  ?

  • Surgically difficult endometriosis : deep endometriosis is the most severe > cystic endometriosis >> stipiccal endometriosis
  • Historically severe endometriosis were classes III and IV of the rAFS classification. When introduced deep endometriosis was not yet discovered

History of classifications

  • 1980 Acosta classification made a distinction between superficial and cystic ovarian endometriosis.
  • 1985 AFS classification is a point scoring system. Essential 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
  • 2008 we published a review and new proposal
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