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An International Terminology for Endometriosis, 2021

Open AccessPublished:October 21, 2021DOI:https://doi.org/10.1016/j.jmig.2021.08.032

      Abstract

      Objective

      Different classification systems have been developed for endometriosis, using different definitions for the disease, the different subtypes, symptoms and treatments. In addition, an International Glossary on Infertility and Fertility Care has been published in 2017 by the International Committee for Monitoring Assisted Reproductive Technologies (ICMART) in collaboration with other organisations. An international working group convened over the development of a classification or descriptive system for endometriosis. As a basis for such system, a terminology for endometriosis was considered a condition sine qua non. The aim of the current study was to develop a set of terms and definitions be prepared on endometriosis that would be the basis for standardization in disease description, classification and research.

      Data Sources

      The working group listed a number of terms relevant to be included in the terminology, documented currently used and published definitions, and discussed and adapted them until consensus was reached within the working group. Following stakeholder review, further terms were added, and definitions further clarified. Although definitions were collected through published literature, the final set of terms and definitions is to be considered consensus-based. After finalization of the first draft, the members of the international societies and other stakeholders were consulted for feedback and comments, which lead to further adaptations.

      Methods of Study Selection

      na

      Tabulation, Integration, and Results

      A list of 49 terms and definitions in the field of endometriosis is presented, including a definition for endometriosis and its subtypes, different locations, interventions, symptoms and outcomes. Endometriosis is defined as a disease characterized by the presence of endometrium-like epithelium and/or stroma outside the endometrium and myometrium, usually with an associated inflammatory process.

      Conclusion

      The current paper outlines a list of 49 terms and definitions in the field of endometriosis. The application of the defined terms aims to facilitate harmonization in endometriosis research and clinical practice. Future research may require further refinement of the presented definitions.

      Keywords

      WHAT DOES THIS MEAN FOR PATIENTS?
      Different definitions are used for endometriosis, endometriosis subtypes, treatments and outcomes. This has significant consequences for research and clinical practice. The current paper is prepared by an international group of experts and lists a number of terms used in endometriosis, with a relevant and appropriate definition. Endometriosis is defined as an inflammatory disease process characterized at surgery by the presence of endometrium-like epithelium and/or stroma outside the endometrium and myometrium, usually with an associated inflammatory process. These definitions should result in harmonisation both in endometriosis research and in clinical practice.

      Introduction

      Endometriosis is considered a spectrum disease with a variety of subtypes and clinical presentations. One consequence of this ambiguity is a large heterogeneity in published studies that are either evaluating diagnostic and therapeutic interventions in endometriosis patients in general, or investigating a certain subgroup based on a published classification, or a disease subtype, with a study-specific definition. The resulting heterogeneity makes it difficult to interpret and summarize published data and draw conclusions on best practice in care for patients with endometriosis.
      The need for standardisation has been repeatedly mentioned by experts in the field [
      • Meuleman C
      • D'Hoore A
      • Van Cleynenbreugel B
      • Tomassetti C
      • D'Hooghe T
      Why we need international agreement on terms and definitions to assess clinical outcome after endometriosis surgery.
      ,
      • Rogers PA
      • D'Hooghe TM
      • Fazleabas A
      • et al.
      Defining future directions for endometriosis research: workshop report from the 2011 World Congress of Endometriosis In Montpellier, France.
      ]. The lack of a uniform and widely accepted terminology for endometriosis has created difficulties in standardizing and in comparing interventions and outcomes. This has further led to difficulty in defining clinical recommendations for endometriosis management [
      • Nisolle M
      • Donnez J
      Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities.
      ].
      In absence of a specific terminology of endometriosis, definitions for endometriosis have been included in international glossaries, such as the International Glossary on Infertility and Fertility Care [
      • Zegers-Hochschild F
      • Adamson GD
      • Dyer S
      • et al.
      The International Glossary on Infertility and Fertility Care, 2017.
      ], the International Statistical Classification of Diseases and Related Health Problems (ICD) published by the World Health Organization (WHO) [https://www.who.int/classifications/icd/icdonlineversions/en/], and other recent publications attempting standardisation [
      • Vanhie A
      • Meuleman C
      • Tomassetti C
      • et al.
      Consensus on Recording Deep Endometriosis Surgery: the CORDES statement.
      ,
      • Johnson NP
      • Hummelshoj L
      • Adamson GD
      • et al.
      World Endometriosis Society consensus on the classification of endometriosis.
      ]. However, the definitions are either not very detailed or elaborate, not widely accepted or not comprehensive for endometriosis. This paper describes a terminology for endometriosis prepared by an international working group representing four international societies with a focus on endometriosis [American Association of Gynecologic Laparoscopists (AAGL), European Society for Gynecological Endoscopy (ESGE), European Society of Human Reproduction and Embryology (ESHRE) and World Endometriosis Society (WES)].

      Materials and Methods

      The current paper is a consensus paper, predominantly based on the opinion of the working group members. The working group constructed a list of terms to be defined on different topics, including endometriosis and its subtypes, locations of the endometriosis lesions, treatments and interventions, and outcome parameters. Published literature and information was collected for the different terms, and definitions were extracted from the key papers. All collected definitions were discussed and, where needed, adapted to fit the aim of the current paper. Whenever definitions were significantly adapted, a justification for the adaptations was formulated in the results section. Before finalisation of the paper, a stakeholder review was organised. The collaborating organisations and individual experts formulated a total of 160 comments, which were tabulated and discussed by the working group. Where relevant, corrections, clarifications and adaptations were made to the text and the terms listed. The review report is available on the societies’ websites.

      Results

      As a starting point for standardisation and to be able to universally use the classification, definitions of terms were structured in four sections: endometriosis, subtypes and locations (Table 1); anatomical spaces and other locations where endometriosis can be detected (Table 2); endometriosis treatments and interventions (Table 3); and outcome parameters (Table 4). For symptoms associated with endometriosis, the definitions are generally clear and can be consulted in other papers [
      • Zegers-Hochschild F
      • Adamson GD
      • Dyer S
      • et al.
      The International Glossary on Infertility and Fertility Care, 2017.
      ,
      • Vitonis AF
      • Vincent K
      • Rahmioglu N
      • et al.
      World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonization Project: II. Clinical and covariate phenotype data collection in endometriosis research.
      ].
      Table 1Terms and definitions for endometriosis, subtypes and locations
      TermDefinitionSource
      EndometriosisA disease characterized by the presence of endometrium-like epithelium and/or stroma outside the endometrium and myometrium, usually with an associated inflammatory process.

      Adapted from [
      • Nisolle M
      • Donnez J
      Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities.
      ,
      • Johnson NP
      • Hummelshoj L
      • Adamson GD
      • et al.
      World Endometriosis Society consensus on the classification of endometriosis.
      ,
      • Whitaker LHR
      • Byrne D
      • Hummelshoj L
      • et al.
      Proposal for a new ICD-11 coding classification system for endometriosis.
      ]
      Peritoneal / superficial endometriosisEndometrium-like tissue lesions involving the peritoneal surface. The lesions can have different appearances and colour e.g. clear, black, etc.Adapted from [
      • World Health Organization
      International Classification of Diseases, 11th Revision (ICD-11).
      ]
      Ovarian endometriotic cyst / endometriomaEndometrium-like tissue in the form of ovarian cysts. They may be either invagination cysts or true cysts with the cyst wall also containing endometrium-like tissue and dark blood-stained fluid, the colour and consistency of which gives rise to the name ‘chocolate cysts’.Adapted from [
      • Whitaker LHR
      • Byrne D
      • Hummelshoj L
      • et al.
      Proposal for a new ICD-11 coding classification system for endometriosis.
      ]
      Deep endometriosisEndometrium-like tissue lesions in the abdomen, extending on or under the peritoneal surface. They are usually nodular, able to invade adjacent structures, and associated with fibrosis and disruption of normal anatomy.Adapted from [
      • Zegers-Hochschild F
      • Adamson GD
      • Dyer S
      • et al.
      The International Glossary on Infertility and Fertility Care, 2017.
      ,
      • Johnson NP
      • Hummelshoj L
      • Adamson GD
      • et al.
      World Endometriosis Society consensus on the classification of endometriosis.
      ,
      • Whitaker LHR
      • Byrne D
      • Hummelshoj L
      • et al.
      Proposal for a new ICD-11 coding classification system for endometriosis.
      ,
      • Koninckx PR
      • Martin DC
      Deep endometriosis: a consequence of infiltration or retraction or possibly adenomyosis externa?.
      ,
      • Cornillie FJ
      Oosterlynck D, Lauweryns JM, Koninckx PR
      Deeply infiltrating pelvic endometriosis: histology and clinical significance.
      ]
      Bowel endometriosisEndometriosis situated inside the bowel wall. Although mostly affecting the rectosigmoid area, lesions can be found also in other parts of the gastrointestinal system, including the appendix. Lesions on the peritoneal surface of the bowel are considered peritoneal endometriosis.Adapted from [
      • World Health Organization
      International Classification of Diseases, 11th Revision (ICD-11).
      ]
      Bladder endometriosisEndometriosis involving the detrusor muscle and/or the bladder epithelium. Lesions on the peritoneal surface of the bladder are considered peritoneal endometriosis.
      Extra-abdominal endometriosisEndometrium-like tissue outside the abdominal cavity.
      Iatrogenic endometriosisLesions resulting from direct or indirect dissemination of endometrium during surgery.
      Adhesions (peritoneal)Bands of fibrous scar tissue that may bind the abdominal and pelvic organs, including the intestines and peritoneum, to each other. They can be dense and thick or filmy and thin. Adhesions can be induced by endometriosis as a result of the inflammatory process of the disease.Adapted from [
      • Zegers-Hochschild F
      • Adamson GD
      • Dyer S
      • et al.
      The International Glossary on Infertility and Fertility Care, 2017.
      ]
      Table 2Terms and definitions for anatomical spaces and other locations where endometriosis can be detected
      TermDefinitionSource
      Pararectal spaceThe retroperitoneal space lying lateral to the rectum on either side. The ureter further divides the pararectal space into the medial pararectal space (Okabayashi space) and lateral pararectal space (Latzko space).[
      • Puntambekar S
      • Manchanda R
      Surgical pelvic anatomy in gynecologic oncology.
      ]
      Paravesical spaceThe retroperitoneal space that lies laterally to the urinary bladder and anterior and superior to the pararectal space.[
      • Puntambekar S
      • Manchanda R
      Surgical pelvic anatomy in gynecologic oncology.
      ]
      Pouch of Douglas (or Recto-uterine pouch) – Cul-de-SacThe space between the posterior uterus and the anterior rectum. It is bordered laterally by the rectouterine folds, peritoneal folds that extend from the rectum to the posterior broad ligament at the cervix.[
      • Heller DS
      Lesions of the Pouch of Douglas: A Review.
      ]
      Presacral spaceA thin, small retroperitoneal space lying behind the rectum is covered by the mesorectum anteriorly and Waldeyer fascia posteriorly.[
      • Puntambekar S
      • Manchanda R
      Surgical pelvic anatomy in gynecologic oncology.
      ]
      Prevesical spaceA small midline retroperitoneal space that lies between the bladder and the anterior abdominal wall. It communicates with the paravesical space on both sides and is enclosed laterally by the lateral umbilical ligament, which is the continuation of the obliterated hypogastric artery onto the abdominal wall[
      • Puntambekar S
      • Manchanda R
      Surgical pelvic anatomy in gynecologic oncology.
      ]
      Rectovaginal spaceThe area behind the pouch of Douglas, enclosed anteriorly by the uterus and the posterior vaginal wall, posteriorly by the rectum, and laterally by the uterosacral and the Mackenrodt ligament[
      • Puntambekar S
      • Manchanda R
      Surgical pelvic anatomy in gynecologic oncology.
      ]
      Retrocervical areaThe area behind the cervix and above the rectovaginal septum.
      Retropubic Space or Space of RetziusThe anatomic space containing areolar connective tissue between the back of the pubic bone and the anterolateral portion of the bladder.Adapted from [
      • Rogers Jr, RM
      Pelvic anatomy seen through the laparoscope A Practical Manual of Laparoscopy: A Clinical Cookbook.
      ]
      Uterosacral ligamentsThe ligaments from the posterior aspect of the uterus to the sacrum.
      Vesicovaginal spaceThe space found between the anterior surface of the vagina and the posterior aspect of the bladder down to the trigone. The space is bordered laterally by the bladder “pillars” that allow for the passage of the inferior vesical arteries, veins and ureter to the bladder.[
      • Rogers Jr, RM
      Pelvic anatomy seen through the laparoscope A Practical Manual of Laparoscopy: A Clinical Cookbook.
      ]
      RectumThe concluding part of the large intestine that terminates in the anus and measures 12–15 cm in length.[
      • Beck DE
      Roberts PL, Saclarides TJ, Senagore AJ, Stamos MJ, Wexner SD
      The ASCRS Textbook of Colon and Rectal Surgery.
      ]
      The terms and definitions are listed in Table 1, Table 2, Table 3, Table 4.

       Endometriosis and its subtypes

      For endometriosis, previous definitions have focussed on pathology or on the symptoms suffered by those with the disease. The WES definition, a strong consensus from 55 expert representatives of 29 national and international organizations (which was considered unanimous, where fewer than 5% of experts disagreed with the definition) introduced the concept that symptoms are an important aspect of ‘disease’ suffered by patients. Without symptoms, the occurrence of lesions per se might not necessarily be considered a disease, given that occurrence of lesions in the absence of symptoms may be considered a ubiquitous finding [
      • Johnson NP
      • Hummelshoj L
      • Adamson GD
      • et al.
      World Endometriosis Society consensus on the classification of endometriosis.
      ,
      • Koninckx PR
      • Oosterlynck D
      • D'Hooghe T
      • Meuleman C
      Deeply infiltrating endometriosis is a disease whereas mild endometriosis could be considered a non-disease.
      ]. A more comprehensive, contemporary characterization of endometriosis has been provided through WES consensus that alludes to other essential elements including incidence, pathogenesis, multifactorial aetiology including genetic factors with possible epigenetic influences, possible effects of environmental exposures, pain syndrome elements, proliferative nature, hormone responsiveness (estrogen-dependence and progesterone-resistance), and overlap with other conditions characterized by pelvic–abdominal pain and infertility (https://endometriosis.ca/endometriosis/). In the International Glossary on Infertility and Fertility Care, endometriosis is defined as a disease characterized by the presence of endometrium-like epithelium and stroma outside the endometrium and myometrium, with further specification that intrapelvic endometriosis can be located superficially on the peritoneum (peritoneal endometriosis), can extend 5mm or more beneath the peritoneum (deep endometriosis) or can be present as an ovarian endometriotic cyst (endometrioma) (Zegers-Hochschild, et al., 2017). For the current terminology, it was decided to focus on the pathology, and define endometriosis-associated symptoms separately. The definition from the International Glossary on Infertility and Fertility Care was further adapted with addition of the most important characteristic of endometriosis “inflammatory”, in line with a recent WHO document stating that endometriosis causes a chronic inflammatory reaction that may result in the formation of scar tissue (adhesions, fibrosis) within the pelvis and other parts of the body [

      World Health Organisation. Endometriosis Fact sheet. Available at: https://wwwwhoint/news-room/fact-sheets/detail/endometriosis. Accessed April 2, 2021.

      ]. The specificities of the subtypes were removed from the definition, as they are defined separately (Table 1). Recent observations suggest to focus on the fibrotic nature of the disease in its definition [
      • Vigano P
      • Candiani M
      • Monno A
      • Giacomini E
      • Vercellini P
      • Somigliana E
      Time to redefine endometriosis including its pro-fibrotic nature.
      ], but further evidence is needed before such adaptation can be made.
      For peritoneal or superficial endometriosis, some cases may only be identified following microscopic histological assessment of macroscopically normal peritoneum. This concept includes that the presence of endometrial-like tissue, and even if only endometrial stroma is found by the pathologist, can be considered endometriosis [
      • Abrao MS
      • Neme RM
      • Carvalho FM
      • Aldrighi JM
      • Pinotti JA
      Histological classification of endometriosis as a predictor of response to treatment.
      ]. However, this was not considered a relevant addition to the definition. A consensus was reached to adapt the definition from the International Classification of Diseases and Related Health Problems (ICD) [

      International Classification of Diseases and Related Health Problems (ICD-11). International Classification of Diseases and Related Health Problems tool (Version 11), (version 04/2020). Available at: https://icdwhoint. Accessed July 8, 2020.

      ], reading “superficial endometriosis of pelvic peritoneum is characterised by ectopic growth and function of endometrial tissue extending 5 millimetres or less under the visceral or parietal pelvic peritoneal surface and appearing as black-brown or light red-orange lesions.” Existing definitions, such as this one, typically define the depth of the lesions and provide examples of the appearances of them. With regard to the depth, it was argued that the depth of the lesions cannot be accurately measured (in mm). Alternatively, it can be assessed whether the lesion is on the peritoneal surface or under the surface, and this could be integrated in the definition. With regards to the appearances of the lesions, it was considered that a specific list of appearances would never be exhaustive and a general statement was included.
      Deep endometriosis is historically defined as extending 5mm under the peritoneal surface [
      • Zegers-Hochschild F
      • Adamson GD
      • Dyer S
      • et al.
      The International Glossary on Infertility and Fertility Care, 2017.
      ,
      • Johnson NP
      • Hummelshoj L
      • Adamson GD
      • et al.
      World Endometriosis Society consensus on the classification of endometriosis.
      ,
      • Whitaker LHR
      • Byrne D
      • Hummelshoj L
      • et al.
      Proposal for a new ICD-11 coding classification system for endometriosis.
      ,
      • Koninckx PR
      • Martin DC
      Deep endometriosis: a consequence of infiltration or retraction or possibly adenomyosis externa?.
      ]. As argued for peritoneal disease, assessing the depth of the infiltration cannot accurately be measured, and therefore it was decided to remove this from the definition.
      The definition of Whitaker and colleagues (including elements from the ICD code) for ovarian endometriosis (cystic) or endometrioma was slightly rephrased, similar to the definition of peritoneal and deep endometriosis [
      • Whitaker LHR
      • Byrne D
      • Hummelshoj L
      • et al.
      Proposal for a new ICD-11 coding classification system for endometriosis.
      ]. As it is not clear whether endometrioma are invagination cysts or true cysts, it was decided to keep both in the definition.
      Although not subtypes, a definition was added for bowel and bladder endometriosis. Fallopian tube, pelvic sidewall and other lesions are to be included as peritoneal endometriosis or deep endometriosis, depending on the depth of the lesions.
      For extrapelvic endometriosis, there was consensus in the group that it should be defined as a separate entity. With regards to defining the possible locations, it was considered that vaginal disease and diaphragmatic disease may be extended abdominal endometriosis (in analogy with oncological definitions). For all other locations (outside the abdominal cavity), it was agreed to use the term extra-abdominal endometriosis and to define it as endometrium-like tissue outside the abdominal cavity.
      Similarly, there was consensus to define iatrogenic endometriosis as an endometriosis subtype. The definition was formulated as lesions resulting from direct or indirect dissemination of endometrium following during surgery. Iatrogenic endometriosis has various manifestations resulting from different surgical procedures. The most common form of iatrogenic endometriosis is abdominal wall endometriosis - commonly involving the skin or subcutaneous layer of abdominal wall, but it can also involve the fascia and muscular layer - following Caesarean section. Other manifestations include episiotomy scar endometriosis or laparoscopic trocar site endometriosis, which involves various layers of abdominal wall, and endometriosis implants at various locations in the abdomen including peritoneum and visceral structures, such as bowel or bladder, attributed to mechanical uterine morcellation.
      Finally, (peritoneal) adhesions were defined based on the definition from the International Glossary on Infertility and Fertility Care, i.e. bands of fibrous scar tissue that may bind the abdominal and pelvic organs, including the intestines and peritoneum, to each other. They can be dense and thick or filmy and thin [
      • Zegers-Hochschild F
      • Adamson GD
      • Dyer S
      • et al.
      The International Glossary on Infertility and Fertility Care, 2017.
      ]. Within the context of endometriosis, adhesions can result from the inflammatory process of the disease and this was specified in the definition.

       Adenomyosis

      Adenomyosis is defined by the International Glossary on Infertility and Fertility Care as a form of endometriosis marked by the presence of endometrium-like epithelium and stroma outside the endometrium in the myometrium [
      • Zegers-Hochschild F
      • Adamson GD
      • Dyer S
      • et al.
      The International Glossary on Infertility and Fertility Care, 2017.
      ]. Different theories have been postulated with regards to adenomyosis and whether or not it is a subtype of endometriosis or a different entity. The first theory was based on similar features between endometriosis and adenomyosis and the fact that they often coexist in the same patient. However, recent reports suggest the theory of two different entities because of specific pathogenic pathways and clinical presentation [
      • Vannuccini S
      • Petraglia F
      Recent advances in understanding and managing adenomyosis.
      ]. It was agreed to define adenomyosis as the presence of ectopic endometrial tissue (endometrial stroma and glands) within the myometrium [
      • Chapron C
      • Vannuccini S
      • Santulli P
      • et al.
      Diagnosing adenomyosis: an integrated clinical and imaging approach.
      ], but not consider it a form of endometriosis

       Anatomical spaces and other locations where endometriosis can be detected

      To support the correct application of any future anatomical descriptive system, the locations where endometriosis lesions can be found were defined (Table 2). The main resources for these definitions include the ICD [

      International Classification of Diseases and Related Health Problems (ICD-11). International Classification of Diseases and Related Health Problems tool (Version 11), (version 04/2020). Available at: https://icdwhoint. Accessed July 8, 2020.

      ], and publications or textbooks on anatomy [
      • Puntambekar S
      • Manchanda R
      Surgical pelvic anatomy in gynecologic oncology.
      ,
      • Heller DS
      Lesions of the Pouch of Douglas: A Review.
      ,
      • Rogers Jr, RM
      Pelvic anatomy seen through the laparoscope A Practical Manual of Laparoscopy: A Clinical Cookbook.
      ].

       Endometriosis treatments and interventions

      Specific terminology for interventions to treat endometriosis is often used, but not consistently. For endometrioma interventions, definitions were deduced from a recent good practice paper for endometrioma surgery [
      • Saridogan E
      • Becker CM
      • et al.
      Working group of ESGE, ESHRE and WES
      Recommendations for the Surgical Treatment of Endometriosis. Part 1: Ovarian Endometrioma¶.
      ,
      • Saridogan E
      • Becker CM
      • et al.
      Working group of ESGE, ESHRE and WES
      Recommendations for the surgical treatment of endometriosis-part 1: ovarian endometrioma.
      ]. Interventions for deep endometriosis were previously defined [
      • Vanhie A
      • Meuleman C
      • Tomassetti C
      • et al.
      Consensus on Recording Deep Endometriosis Surgery: the CORDES statement.
      ] and good practice recommendations formulated [
      • Keckstein J
      • Becker CM
      • et al.
      Working group of ESGE, ESHRE and WES
      Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis †‡¶.
      ,
      • Keckstein J
      • Becker CM
      • et al.
      Working group of ESGE, ESHRE and WES
      Recommendations for the surgical treatment of endometriosis Part 2: deep endometriosis †‡¶.
      ]. An overview of the different interventions and their definitions is available in Table 3.
      Table 3Terms and definitions for treatments and interventions used in the context of endometriosis
      TermDefinitionSource
      Reproductive surgerySurgical procedures performed to diagnose, conserve, correct and/or improve reproductive function. Surgery for contraceptive purposes, such as tubal ligation, are also included within this term.Adapted from [
      • Zegers-Hochschild F
      • Adamson GD
      • Dyer S
      • et al.
      The International Glossary on Infertility and Fertility Care, 2017.
      ]
      Superficial excisionSuperficial excision of serosal and subserosal endometriosis (mechanically, with electrosurgery, laser or other energy source) that does not require suturing/closure.[
      • Vanhie A
      • Meuleman C
      • Tomassetti C
      • et al.
      Consensus on Recording Deep Endometriosis Surgery: the CORDES statement.
      ]
      Partial thickness discoid excisionSelective excision of the bowel/bladder endometriosis lesion (mechanically, with electrosurgery, laser or other energy source) without entering the bowel/bladder lumen, that requires suturing/closure (i.e. closure of a muscularis defect without a mucosal defect in the bowel wall). Shaving is a form of partial thickness discoid excision.Adapted from [
      • Vanhie A
      • Meuleman C
      • Tomassetti C
      • et al.
      Consensus on Recording Deep Endometriosis Surgery: the CORDES statement.
      ]
      Full thickness discoid excisionSelective excision of the bowel endometriosis lesion (mechanically, with electrosurgery, laser or other energy source) with opening of the bowel lumen followed by closure of the bowel.Subtypes:
      • (1)
        Open full thickness disc excision: excision with opening of lumen followed by closure
      • (2)
        Closed full thickness disc excision: excision with stapler
      [
      • Vanhie A
      • Meuleman C
      • Tomassetti C
      • et al.
      Consensus on Recording Deep Endometriosis Surgery: the CORDES statement.
      ]
      Bowel resection and re-anastomosisResection of a bowel segment affected by endometriosis followed by re-anastomosis by any means.[
      • Vanhie A
      • Meuleman C
      • Tomassetti C
      • et al.
      Consensus on Recording Deep Endometriosis Surgery: the CORDES statement.
      ]
      Bladder wall resectionSelective excision of the bladder endometriosis lesion (mechanically, with electrosurgery, laser or other energy source) with or without opening of the bladder lumen.Subtypes:
      • (1)
        Partial thickness bladder resection without opening of the bladder lumen requiring suturing.
      • (2)
        Full thickness bladder wall resection (partial cystectomy) with opening of the bladder lumen requiring suturing and closure of the bladder wall.
      Adapted from [
      • Vanhie A
      • Meuleman C
      • Tomassetti C
      • et al.
      Consensus on Recording Deep Endometriosis Surgery: the CORDES statement.
      ]
      Cystectomy (total)Excision of the cyst wall mechanically by gentle traction and counter-traction to dissect the capsule from the ovarian parenchyma. Electrosurgery, laser, haemostatic agents, and/or other energy sources could be used to facilitate the process and to provide haemostasis.Adapted from (Working group of ESGE ESHRE and WES, et al., 2017a, Working group of ESGE ESHRE and WES, et al., 2017b)
      Partial ovarian cystectomyA combination of excisional and ablative surgery. A large part of the endometrioma is first excised according to the cystectomy technique, followed by vaporisation of the remaining endometrioma close to the hilus using energy such as electrosurgeryAdapted from [
      • Donnez J
      Lousse JC, Jadoul P, Donnez O, Squifflet J
      Laparoscopic management of endometriomas using a combined technique of excisional (cystectomy) and ablative surgery.
      ]
      AblationObliteration of the inner surface of the cyst wall in cases of endometriomas and/or endometriotic lesions in cases of peritoneal endometriosis using, electro- or ultrasound high frequency-modes, laser, or plasma energyAdapted from (Working group of ESGE ESHRE and WES, et al., 2017a, Working group of ESGE ESHRE and WES, et al., 2017b)
      Coagulation or FulgurationDestruction of the inner surface of the cyst wall in cases of endometriomas and/or endometriotic lesions in cases of peritoneal endometriosis using electrosurgery.
      UreterolysisSelective dissection of the ureter from a lesion, either mechanically or with electrosurgery, laser or any other energy source. Restoration of the anatomy of the ureter intending to restore normal function through lysis and/or resection of adhesions.Subtypes:
      • (1)
        Without opening of the ureteric wall
      • (2)
        With opening and re-suturing of the ureteric wall.
      Adapted from [
      • Vanhie A
      • Meuleman C
      • Tomassetti C
      • et al.
      Consensus on Recording Deep Endometriosis Surgery: the CORDES statement.
      ]
      Ureteral segmental resectionResection of a ureteral segment affected by endometriosis followed by ipsilateral uretero-ureteral re-anastomosis or ureteral reimplantation into the bladder.[
      • Vanhie A
      • Meuleman C
      • Tomassetti C
      • et al.
      Consensus on Recording Deep Endometriosis Surgery: the CORDES statement.
      ]
      Medically assisted reproduction (MAR)Reproduction brought about through various interventions, procedures, surgeries and technologies to treat different forms of fertility impairment and infertility. These include ovulation induction, ovarian stimulation, ovulation triggering, all assisted reproductive technology (ART) procedures, uterine transplantation and intra-uterine, intracervical and intravaginal insemination with semen of husband/partner or donor.[
      • Zegers-Hochschild F
      • Adamson GD
      • Dyer S
      • et al.
      The International Glossary on Infertility and Fertility Care, 2017.
      ]
      Fertility preservationVarious interventions, procedures and technologies, including cryopreservation of gametes, embryos or ovarian tissue, to preserve reproductive capacity.Adapted from [
      • Zegers-Hochschild F
      • Adamson GD
      • Dyer S
      • et al.
      The International Glossary on Infertility and Fertility Care, 2017.
      ]
      The definition of reproductive surgery from the International Glossary on Infertility and Fertility Care was specified towards female patients, as the original definition includes both male and female reproductive surgery [
      • Zegers-Hochschild F
      • Adamson GD
      • Dyer S
      • et al.
      The International Glossary on Infertility and Fertility Care, 2017.
      ].
      Bowel shaving was previously defined as superficial excision of bowel serosal and subserosal endometriosis (mechanically, with electrosurgery, laser or other energy source) that does not require suturing/closure [
      • Vanhie A
      • Meuleman C
      • Tomassetti C
      • et al.
      Consensus on Recording Deep Endometriosis Surgery: the CORDES statement.
      ], but other definitions and interpretations have also been proposed and applied. The working group considered shaving to be a form of partial thickness discoid excision, but agreement on a more specific definition could not be reached. The working group therefore recommends using the more accurate and specific terms included in this terminology and abandon the term “shaving”.
      With regards to ablation, the term is limited to obliteration of the inner surface of the cyst wall in cases of endometriomas and/or endometriotic lesions in cases of peritoneal endometriosis using electro- or ultrasound high frequency-modes, laser, or plasma energy. Non-surgical treatment options, such as sclerotherapy, can be defined as the destruction of the endometrial tissue using, for example, alcohol installation.
      For the different surgical techniques and definitions, it can be considered that surgery can be complete or incomplete, i.e. with visually fibrotic and/or endometriotic lesions left in place. This was not considered a relevant addition to the definitions, but should be included in the patient records.

       Outcome parameters

      The lack of internationally agreed outcome parameters for endometriosis interventions largely affects the value of individual studies when attempting to draw conclusions for clinical practice [
      • Meuleman C
      • Tomassetti C
      • D'Hoore A
      • et al.
      Surgical treatment of deeply infiltrating endometriosis with colorectal involvement.
      ]. Specifically for outcomes in endometriosis (pain, recurrence, quality of life [QoL]), their definition may affect the conclusions from the studies. A recently published consensus defines a core outcome set that should be implemented when evaluating potential treatments for endometriosis to standardise outcome selection, collection and reporting [
      • Duffy J
      • Hirsch M
      • Vercoe M
      • et al.
      A core outcome set for future endometriosis research: an international consensus development study.
      ], yet this outcome set does not include a specific definition of all outcomes. Pain, infertility and QoL are included in the terminology as symptoms or outcomes with previously published definitions (Table 4). With regards to evaluating pain outcomes, a patient-based 11-point Numerical Rating Score, in which the preoperative and post-operative symptoms are given by the patient, allows a better evaluation of the post-operative pain situation as well as the evaluation of de novo pain symptoms possibly associated with a specific type of surgery, when compared with the rating of symptom prevalence and severity by others (physicians, nurses) [
      • Vincent K
      • Kennedy S
      • Stratton P
      Pain scoring in endometriosis: entry criteria and outcome measures for clinical trials. Report from the Art and Science of Endometriosis meeting.
      ]. For QoL outcomes, preference should be given to validated QOL questionnaires, such as the Endometriosis Health Profile Questionnaire (EHP-5 and EHP-30). Recurrence has been defined depending on symptom or lesion recurrence, but a time frame was not included. Further terms included are complications (according to the Clavien-Dindo grading), sequelae and residual disease.
      Table 4Terms and definitions for outcome parameters of endometriosis treatments/interventions
      TermDefinitionSource
      Core outcomes in endometriosisA set of thirteen core outcomes identified for endometriosis trials.
      • -
        Core outcomes for pain and quality of life (three) are: overall pain, improvement in the most troublesome symptom, and quality of life.
      • -
        Core outcomes for infertility (eight) include: viable intrauterine pregnancy confirmed by ultrasound, pregnancy loss, termination of pregnancy, live birth, time to pregnancy leading to live birth, gestational age at delivery, birthweight, neonatal mortality, and major congenital abnormalities.
      • -
        Two core outcomes applicable to all endometriosis trials are: adverse events and patient satisfaction with treatment.
      [
      • Vanhie A
      • Meuleman C
      • Tomassetti C
      • et al.
      Consensus on Recording Deep Endometriosis Surgery: the CORDES statement.
      ]
      FertilityThe capacity to establish a clinical pregnancy.[
      • Zegers-Hochschild F
      • Adamson GD
      • Dyer S
      • et al.
      The International Glossary on Infertility and Fertility Care, 2017.
      ]
      InfertilityA disease characterized by the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse or due to an impairment of a person's capacity to reproduce either as an individual or with his/her partner.Adapted from [
      • Zegers-Hochschild F
      • Adamson GD
      • Dyer S
      • et al.
      The International Glossary on Infertility and Fertility Care, 2017.
      ,
      • World Health Organization
      International Classification of Diseases, 11th Revision (ICD-11).
      ]
      Endometriosis-associated infertilityImpaired fertility in which the female has a prior diagnosis of endometriosis.
      PregnancyA state of reproduction beginning with implantation of an embryo in a woman and ending with the complete expulsion and/or extraction of all products of implantation.[
      • Zegers-Hochschild F
      • Adamson GD
      • Dyer S
      • et al.
      The International Glossary on Infertility and Fertility Care, 2017.
      ]
      PainVarious different pain patterns have been described for endometriosis including dysmenorrhoea (menstrual period pain), dyspareunia (pain related to sexual activity), dyschezia (bowel related pain), dysuria (urinary tract related pain), mid-cycle pain (mittelschmerz) that is often related to ovulation, non-cyclic pelvic pain.Adapted from [
      • Vanhie A
      • Meuleman C
      • Tomassetti C
      • et al.
      Consensus on Recording Deep Endometriosis Surgery: the CORDES statement.
      ]
      Quality of life (QoL)The “individuals' perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns”. It is a broad ranging concept incorporating in a complex way the persons' physical health, psychological state, level of independence, social relationships, personal beliefs and their relationships to salient features of the environment. Numerous quality of life measures are available.[
      • World Health Organization
      Programme on mental health: WHOQOL user manual.
      ]
      Complication (GRADE I)Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic or radiological interventions. Allowed therapeutic regimens are: drugs as antiemetics, antipyretics, analgesics, diuretics, electrolytes, and physiotherapy. This grade also includes wound infections opened at the bedside[
      • Dindo D
      Demartines N, Clavien PA
      Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
      ]
      Complication (GRADE II)Requiring pharmacological treatment with drugs other than such allowed for grade I complications

      Blood transfusions and total parenteral nutrition are also included
      [
      • Dindo D
      Demartines N, Clavien PA
      Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
      ]
      Complication (GRADE III)Requiring surgical, endoscopic or radiological intervention

      Grade IIIa: Intervention not under general anaesthesia

      Grade IIIb: Intervention under general anaesthesia
      [
      • Dindo D
      Demartines N, Clavien PA
      Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
      ]
      Complication (GRADE IV)Life-threatening complication (including central nervous system complications)
      Brain haemorrhage, ischemic stroke, subarachnoid bleeding, but excluding transient ischemic attacks. IC = intermediate care; ICU = intensive care unit.
      requiring IC/ICU management

      Grade IVa: Single organ dysfunction (including dialysis)

      Grade IVb: Multiorgan dysfunction
      [
      • Dindo D
      Demartines N, Clavien PA
      Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
      ]
      Complication (GRADE V)Death of a patient[
      • Dindo D
      Demartines N, Clavien PA
      Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
      ]
      SequelaeAn ‘after-effect’ of surgery that is inherent to the procedure, e.g. inability to conceive after removing the uterus[
      • Vanhie A
      • Meuleman C
      • Tomassetti C
      • et al.
      Consensus on Recording Deep Endometriosis Surgery: the CORDES statement.
      ]
      RecurrenceLesion recurrence on reoperation or imaging after previous complete excision of the disease.
      • (1)
        Symptom based suspected recurrence: Symptom recurrence based on patient history, but not proven/confirmed by imaging and/or surgery
      • (2)
        Imaging based suspected recurrence: Endometriosis recurrence based on imaging (in patients with or without symptoms).
      • (3)
        Laparoscopically proven recurrence: Recurrence of visual endometriosis without histological proof: during laparoscopy endometriosis is visually observed but either not biopsied or biopsied without histologically proven endometriosis.
      • (4)
        Histologically proven recurrence: Recurrence of histologically proven endometriosis: during laparoscopy endometriosis is visually observed and confirmed histologically.
      Adapted from [
      • Vanhie A
      • Meuleman C
      • Tomassetti C
      • et al.
      Consensus on Recording Deep Endometriosis Surgery: the CORDES statement.
      ]
      Residual diseaseEndometriosis lesions not completely removed at the time of surgery.
      low asterisk Brain haemorrhage, ischemic stroke, subarachnoid bleeding, but excluding transient ischemic attacks.IC = intermediate care; ICU = intensive care unit.

      Discussion

      The current paper outlines a list of 49 terms and definitions in the field of endometriosis, as a result of a consensus-based approach. The list includes a definition for endometriosis and its subtypes, different locations, interventions, symptoms and outcomes. The aim of this terminology is to provide a standardized language for the description of endometriosis, to be disseminated and applied widely and to be used as the basis for a new descriptive system for endometriosis. Furthermore, the use of the defined terms should lead to harmonization in endometriosis research and clinical practice. Further research in endometriosis, its diagnosis and pathogenesis may allow further refinement of the definitions provided.

      Data availability statement

      All data are incorporated into the article.

      Authors’ roles

      CT, NPJ and JP contributed to conception and design and drafting the content of the paper. NV provided technical support. All other authors participated in discussion and critically revising the draft. All authors approved the final version.

      Funding

      The meetings and activities of the working group were funded by the American Association of Gynecologic Laparoscopists, European Society for Gynaecological Endoscopy, European Society of Human Reproduction and Embryology and World Endometriosis Society.

      Conflict of interest

      A.W.H. reports grant funding from the MRC, NIHR, CSO, Wellbeing of Women, Roche Diagnostics, Astra Zeneca, Ferring, Charles Wolfson Charitable Trust, Standard Life, Consultancy fees from Roche Diagnostics, AbbVie, Nordic Pharma and Ferring, outside the submitted work. In addition, A.W.H. has a patent Serum biomarker for endometriosis pending. N.P.J. reports personal fees from Abbott, Guerbet, Myovant Sciences, Vifor Pharma, Roche Diagnostics outside the submitted work; he is also President of the World Endometriosis Society and chair of the trust board. S.M. reports grants and personal fees from AbbVie, and personal fees from Roche outside the submitted work. C.T. reports grants, nonfinancial support and other from Merck SA, non-financial support and other from Gedeon Richter, non-financial support from Ferring Pharmaceuticals, outside the submitted work and without private revenue. K.T.Z. reports grants from Bayer Healthcare, MDNA Life Sciences, Roche Diagnostics Inc, Volition Rx, outside the submitted work; she is also a Board member (Secretary) of the World Endometriosis Society and World Endometriosis Research Foundation, Research Advisory Board member of Wellbeing of Women, UK (research charity), and Chair, Research Directions Working Group, World Endometriosis Society. J.P reports personal fees from Hologic, Inc., outside the submitted work; he is also a member of the executive boards of ASRM and SRS. The other authors had nothing to disclose.

      Acknowledgements

      The authors would like to acknowledge the experts on endometriosis that contributed to the stakeholder review and thank them for their useful comments.

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