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.

Authors

Yuta Ueno, Hanako Kaseki, Tatsunori Shiraishi, Fumi Nagawa, Aya Ono, Tomoaki Fukagawa, Go Ichikawa, Shunji Suzuki, Masao Ichikawa

Published in

Gynecology and pelvic medicine. Volume 8. Pages 14. Epub Jun 26, 2025.

Abstract

Endometriosis affects approximately 10% of women of reproductive age globally and is a leading cause of chronic pelvic pain and infertility. Accurate classification is essential for preoperative diagnosis, surgical planning, and research. However, systems like the revised American Society for Reproductive Medicine (r-ASRM) rely on intraoperative findings and are not applicable preoperatively. This narrative review addresses this gap by examining three emerging classification systems-#Enzian, American Association of Gynecologic Laparoscopists (AAGL) 2021, and Numerical Multi-Scoring System of Endometriosis (NMS-E)-with a focus on their utility in pre-surgical assessment.
We conducted a narrative literature review using PubMed, Embase, and Scopus covering the period from January 2015 to January 2025. A total of 66 articles related to the #Enzian classification and 19 articles on the AAGL 2021 classification were initially identified. Among them, 7 articles on #Enzian (3 original research articles and 4 reviews) and 5 articles on AAGL (2 original studies and 3 reviews) were selected based on their clinical relevance and methodological rigor. In addition, 5 original studies on the NMS-E system conducted at our institution were included. Further literature related to surgical planning, imaging techniques, and classification validation was also reviewed to support the comparative analysis.
The r-ASRM system remains widely used but lacks correlation with deep endometriosis and is not applicable preoperatively. The #Enzian system provides detailed anatomical mapping and is compatible with imaging but lacks scoring for pain and adhesions. It also does not offer a composite severity score or a specific evaluation of pouch of Douglas obliteration. Similarly, the AAGL 2021 classification introduces a surgical complexity score but does not assess pain or adhesions in detail and lacks specific evaluation of uterosacral ligament involvement. The NMS-E system uniquely integrates pelvic examination and ultrasound findings into an E-score reflecting lesion, pain, and adhesion severity. Validation studies demonstrate a strong correlation with surgical duration (r=0.724, P<0.01). Patients with lower NMS-E adhesion scores had better postoperative fertility outcomes (P<0.05). While #Enzian and AAGL 2021 are gaining international adoption, NMS-E remains in the early stages of clinical uptake.
Each system contributes to improved preoperative assessment but has limitations. NMS-E adds value by incorporating symptoms and adhesion scoring. No system is yet ideal; further integration and validation across diverse clinical settings are needed. This review provides comparative insights to support classification system refinement and practical application.

PMID:
42211905
Bibliographic data and abstract were imported from PubMed on 17 Sep 2026.

Read full publication at:
Please sign in to see all details.

Stats

1-terrible, 9-excellent. How would you rate this publication? Sign in in to submit your rating.

Post a comment

You need to be signed in to post comments. You can sign in here.

Comments

There are no comments yet.