A C TA Obstetricia et Gynecologica

AOGS C O M M E N T A R Y

The rASRM score and the Enzian classification

for endometriosis: their strengths and weaknesses
DIETMAR HAAS1,2 , OMAR SHEBL3 , ANDREAS SHAMIYEH4 & PETER OPPELT1,2
1
Department of Obstetrics and Gynecology, Linz General Hospital, Linz, Austria, 2 Department of Gynecology,
Erlangen University Hospital, Erlangen, Germany, 3 Women’s General Hospital, Linz, Austria, and 4 Ludwig Boltzmann
Institute for Operative Laparoscopy, 2nd Surgical Department, Academic Teaching Hospital, Linz General Hospital,
Linz, Austria

Key words Abstract

Endometriosis, rASRM score, Enzian
classification, Endometriosis Fertility Index,
classification
Correspondence
Dietmar Haas, MD, Allgemeines Krankenhaus
Linz, Abteilung für Gynäkologie und
Geburtshilfe, Krankenhausstrasse 9, A-4021
Linz, Austria.
E-mail: dr.haas@hotmail.com
Conflict of interest
The authors have stated explicitly that there
are no conflicts of interest in connection with
this article.
Please cite this article as: Haas D, Shebl O,
Shamiyeh A, Oppelt P. The rASRM score and
the Enzian classification for endometriosis:
their strengths and weaknesses. Acta Obstet
Gynecol Scand 2012;91:
DOI:10.1111/aogs.12026.
The revised American Society for Reproductive Medicine (rASRM) score is currently
the best-known classification of endometriosis and is the one most widely used
throughout the world. It is relatively easy to use, but it does not take into account the
involvement of retroperitoneal structures with deeply infiltrating endometriosis. For
this reason, the Enzian classification was developed as a supplement to the rASRM
score, in order to provide a morphologically descriptive classification of deeply
infiltrating endometriosis. The Enzian classification currently has a poor level of
international acceptance and is mainly used in the German-speaking countries. It
was revised in 2011 and is now also easier to use. This article describes the strengths
and weaknesses of the rASRM score and the Enzian classification and their common
potential for classifying endometriosis.
Abbreviations: AFS, American Fertility Society; rAFS, revised American Fertility
Society score; rASRM, revised American Society for Reproductive Medicine score;
TNM, classification of malignant tumors (Tumor, lymph Nodes, Metastasis).

Received: 9 July 2012

Accepted: 24 September 2012

DOI: 10.1111/aogs.12026

scientifically based and should be generally recognized and

Introduction
Endometriosis is one of the most frequent benign diseases
in women of childbearing age. It is estimated that 5–15% of
women of childbearing age are affected by it (1). A common
terminology in the form of a staging system is needed in
order to allow international comparison of this frequent dis-
ease and make it possible to exchange information regarding
treatment and treatment successes. From the medical point of
view, the requirements for this type of classification include
a morphological description of the disease and simplicity of
use. In addition, the staging system should be empirically and
used (2). Optimally, it would also include cardinal symptoms,
such as pain and sterility.
Sampson (3) developed a classification model as early as
1921, and other classifications by Acosta et al. (4) and, in the
German-speaking countries, by Albrecht et al. (5) followed.
In 1979, the American Fertility Society (AFS) presented the
AFS score (6), which, following its revision in 1985 (rAFS
score; 7), became established as the most widely used classifi-
cation system throughout the world. It was renamed in 1996
as the revised American Society for Reproductive Medicine
(rASRM) score (8).


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The rASRM score and the Enzian classification D. Haas et al.

Figure 1. The revised American Society for Reproductive Medicine (rASRM) classification of endometriosis (reproduced with permission from Fertil
Steril. 1997;67:819).

The rASRM score obliteration. Finally, all of the points assigned are summed,
and the resulting point scores are classified into four grades
The rASRM score (Figure 1; 8) is, as such, a genuine scoring of severity:
system. Values are assigned to endometriosis lesions in the
peritoneum and ovaries using points that correspond to the • Stage I (minimal), 1–5 points
size of the lesions. By analogy, points are also assigned for • Stage II (mild), 6–15 points
adhesions on the ovaries and Fallopian tubes. In addition, • Stage III (moderate), 16–40 points
there are points for partial or complete posterior cul-de-sac • Stage IV (severe), >40 points

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D. Haas et al.
Figure 2. The revised Enzian classification of endometriosis.
The optimal list of requirements for an endometriosis
classification described above is only partly met by the
rASRM score, because pain, sterility and deeply infiltrating
endometriosis are not included in it.
Advantages of the rASRM score are that it is currently the
best-known system and is the one most widely used through-
out the world. It is relatively easy to use, and the four grades
of severity are easy for patients to understand.
Disadvantages of the rASRM score include that the grades
of severity I–IV do not as such provide any information about
morphological involvement with endometriosis. Particularly
when there is involvement of the ovaries and the posterior cul-
de-sac, the reproducibility of the staging findings is limited
(9,10). The rASRM score does not take into account involve-
ment of retroperitoneal structures with deeply infiltrating
endometriosis, and there is only poor correlation between
the extent of endometriosis and pain (11). There is also only
poor correlation between the extent of endometriosis and
sterility (12).
The first two of the above disadvantages lie in the nature of
the rASRM score itself. A particular difficulty, however, is the
fact that the rASRM score only correlates poorly with pain and
sterility. For this reason, Adamson and Pasta (13) developed
the Endometriosis Fertility Index. This endometriosis staging
system represents a clinical score and supplements the weak
clinical information about sterility and fertility provided by
the rASRM score.
In view of the lack of description of retroperitoneal struc-
tures involving deeply infiltrating endometriosis, the Enzian
classification was developed in 2005 (14). This was not in-
tended to compete with the rASRM score, but rather to
supplement it with a description of deeply infiltrating en-

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The rASRM score and the Enzian classification
dometriosis. Problematic aspects of the Enzian classification
proved to be its poor level of international acceptance, the
fact that it was complicated to use, and there was sometimes
unintended overlap with the rASRM score (15). For these
reasons, it was revised in 2010 and 2011 (16,17) in order to
simplify and optimize the classification.
The revised Enzian classification
The revised version (Figure 2) combines morphological
structures into compartments in order to simplify the sys-
tem. Retroperitoneal structures are divided into the following
three compartments:
• Compartment A, rectovaginal septum and vagina
• Compartment B, sacrouterine ligament to pelvic wall
• Compartment C, rectum and sigmoid colon
Severity was rated in the same way for all compartments,
as follows:
• Grade 1, invasion <1 cm
• Grade 2, invasion 1–3 cm
• Grade 3, invasion >3 cm
Deep invasion of endometriosis beyond the lesser pelvis
and invasion of organs can also be registered separately
in the Enzian classification. The prefix “F” stands for
“far” or “foreign,” because it refers to retroperitoneal dis-
tant locations (FA = adenomyosis, FB = involvement of
the bladder, FU = intrinsic involvement of the ureter,
FI = bowel disease cranial to the rectosigmoid junction and
FO (“other”) = other locations, such as abdominal wall en-
dometriosis).
The nomenclature is analogous with the TNM classifica-
tion of malignant tumors, i.e. Enzian: A0–3 B0–3 C0–3 FA,
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The rASRM score and the Enzian classification
Table 1. Advantages and disadvantages of the revised American Society for Reproductive Medicine (rASRM) and Enzian classifications.
rASRM
Advantages Known throughout the world and most widely used
Easy to use
Severity grades I–IV are easy for patients to understand
Disadvantages Severity grades I–IV do not in themselves provide any
information about morphological involvement with
endometriosis
Limited reproducibility of the staging findings when the ovaries
and posterior cul-de-sac are involved
Does not take retroperitoneal structures and deeply infiltrating
endometriosis into account
Poor correlation between the extent of endometriosis and pain
Poor correlation between the extent of endometriosis and
sterility
FB, FU, FI, FO. Distant locations are only stated when present.
For example, the designation for a 2 cm focus in the rectum,
a 0.5 cm focus on the sacrouterine ligament and adenomyosis
would be Enzian: A0 B1 C2 FA.
In the Enzian classification, the scoring process (0–3) is
carried out using the size of involvement in compartments
A, B and C. Only the largest focus in each compartment is
evaluated (if several are present).
Advantages of the Enzian classification include that the
location and extent of involved retroperitoneal structures
can be described with relative morphological precision, as
a supplement to the rASRM score. By analogy with the TNM
classification, suspected involvement with deeply infiltrat-
ing endometriosis can be well described preoperatively using
a clinical Enzian classification, such as cEnzian: A1 B1 C0
when there is suspected involvement in compartments A and
B. The preoperative clinical examination has relatively good
sensitivity and specificity for the diagnosis of deeply infiltrat-
ing endometriosis (18–20). As a result of the relatively good
morphological description provided, additional aspects, such
as the anticipated operating time for deeply infiltrating en-
dometriosis (21), can be calculated.
Disadvantages of the Enzian classification are that at the
moment, the international acceptance of the classification is
still poor. The Enzian classification is currently used almost
exclusively in the German-speaking countries. Its use has
been substantially simplified, but it still appears to be more
complicated than the rASRM score. For patients, the classi-
fication is not understandable, or understandable only with
difficulty. Few research studies have been published on the
classification in international journals. There are currently no
data available on whether the Enzian classification correlates
with symptoms such as pain or sterility and infertility.
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D. Haas et al.
Enzian
Involved retroperitoneal structures can be given a relatively
precise morphological description
Suspected involvement of deeply infiltrating endometriosis can
be well described preoperatively using a clinical Enzian
classification
Still poor level of international acceptance
More complicated to use than the rASRM score
The classification is difficult or impossible for patients to
understand
Poor state of published research in international journals
Currently, no data on whether the Enzian classification
correlates with clinical symptoms
In Germany, Austria, Switzerland and South Tyrol (Italy),
there are currently 47 endometriosis competence centers with
certification at levels I (n = 17), II (n = 10) and III (n = 20;
22). Certification is carried out by the Endometriosis Re-
search Foundation (Stiftung Endometriose Forschung; SEF).
Within the framework of the certification and recertification
processes, all level III competence centers are obliged to use
both the rASRM and the Enzian classifications. It can there-
fore be expected that there is greater familiarity with and
acceptance of the Enzian classification in these countries.
The state of published research with regard to the Enzian
classification is currently still poor. Further studies are ur-
gently required in order to explore its clinical relevance. For
the time being, the Enzian classification must be regarded
purely as morphologically descriptive.
Conclusions
At present, the methods used to classify endometriosis
strongly resemble a modular assembly system. The rASRM
score and the Enzian classification supplement each other
fairly well in describing the morphological extent of en-
dometriosis (Table 1). However, the rASRM score shows only
poor correlation with the clinical symptoms of the disease.
With regard to the Enzian classification, it has not yet been
evaluated whether it correlates with clinical findings. Ad-
ditional classifications, such as the Endometriosis Fertility
Index, are therefore needed in order to be able to represent
all the different facets of endometriosis as a disease.
As this modular system in no sense provides a common
terminology yet, a new classification is urgently needed, both
from the medical point of view and from the point of view of
the patients affected. It is only in this way that it will become
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possible to reflect all the clinical and morphological facets of
endometriosis satisfactorily.
References
1. Schweppe KW. Endometriose – Eine Erkrankung ohne
Lobby. [Endometriosis – a disease that has no lobby]. (In
German, no Abstract available). Zentralbl Gynakol.
2003;125:233.
2. Adamson GD. Endometriosis classification: an update. Curr
Opin Obstet Gynecol. 2011;23:213–20.
3. Sampson JA. Perforating hemorrhagic (chocolate) cysts of
the ovary. Arch Surg. 1921;3:245–61.
4. Acosta AA, Buttram VC Jr, Besch PK, Malinak LR, Franklin
RR, Vanderheyden JD. A proposed classification of pelvic
endometriosis. Obstet Gynecol. 1973;42:19–25.
5. Albrecht H. Die Endometriose. In: Seitz L, Amreich AI (eds).
Biologie und Pathologie des Weibes: Ein Handbuch der
Frauenheilkunde und der Geburtshilfe. [Biology and
pathology of the woman: a manual of gynecology and
obstetrics.] 2nd edn. vol. 4. Berlin: Urban & Schwarzenberg,
1955. pp. 190–288.
6. Classification of endometriosis. The American Fertility
Society. Fertil Steril. 1979;32:633–4.
7. Revised American Fertility Society classification of
endometriosis: 1985. Fertil Steril. 1985;43:351–2.
8. Revised American Society for Reproductive Medicine
classification of endometriosis: 1996. Fertil Steril.
1997;67:817–21.
9. Hornstein MD, Gleason RE, Orav J, Haas ST, Friedman AJ,
Rein MS, et al. The reproducibility of the revised American
Fertility Society classification of endometriosis. Fertil Steril.
1993;59:1015–21.
10. Vercellini P, Vendola N, Bocciolone L, Rognoni MT, Carinelli
SG, Candiani GB. Reliability of the visual diagnosis of
ovarian endometriosis. Fertil Steril. 1991;56:1198–200.
11. Vercellini P, Trespidi L, De Giorgi O, Cortesi I, Parazzini F,
Crosignani PG. Endometriosis and pelvic pain: relation to
disease stage and localization. Fertil Steril. 1996;65:299–304.
12. Guzick DS, Silliman NP, Adamson GD, Buttram VC Jr, Canis
M, Malinak LR, et al. Prediction of pregnancy in infertile
women based on the American Society for Reproductive

C 2012 The Authors
Acta Obstetricia et Gynecologica Scandinavica 
C 2012 Nordic Federation of Societies of Obstetrics and Gynecology
The rASRM score and the Enzian classification
Medicine’s revised classification of endometriosis. Fertil
Steril. 1997;67:822–9.
13. Adamson GD, Pasta DJ. Endometriosis fertility index: the
new, validated endometriosis staging system. Fertil Steril.
2010;94:1609–15.
14. Tuttlies F, Keckstein J, Ulrich U, Possover M, Schweppe KW,
Wustlich M, et al. ENZIAN-Score, eine Klassifikation der tief
infiltrierenden Endometriose. [ENZIAN-score, a
classification of deep infiltrating endometriosis]. (In German,
abstract available.) Zentralbl Gynakol. 2005;127:275–81.
15. Haas D, Chvatal R, Habelsberger A, Wurm P, Schimetta W,
Oppelt P. Comparison of revised American Fertility Society
and ENZIAN staging: a critical evaluation of classifications of
endometriosis on the basis of our patient population. Fertil
Steril. 2011;95:1574–8.
16. 6th Conference of the Stiftung Endometriose Forschung
[Foundation for Endometriosis Research], Hotel Enzian,
Weissensee, Austria, February 19–21, 2010.
17. The revised Enzian classification. [Consensus meeting, 7th
Conference of the Stiftung Endometriose Forschung
(Foundation for Endometriosis Research), Hotel Enzian,
Weissensee, Austria, February 25–27, 2011.] Weissensee,
Austria: Stiftung Endometriose Forschung (SEF), 2011.
18. Bazot M, Lafont C, Rouzier R, Roseau G, Thomassin-Naggara
I, Daraı̈ E. Diagnostic accuracy of physical examination,
transvaginal sonography, rectal endoscopic sonography, and
magnetic resonance imaging to diagnose deep infiltrating
endometriosis. Fertil Steril. 2009;92:1825–33.
19. Hudelist G, Ballard K, English J, Wright J, Banerjee S,
Mastoroudes H, et al. Transvaginal sonography vs. clinical
examination in the preoperative diagnosis of deep infiltrating
endometriosis. Ultrasound Obstet Gynecol. 2011;37:480–7.
20. Candiani M. Current guidelines for treatment of
endometriosis without laparoscopy. Drugs Today (Barc).
2005;41 Suppl A:11–5.
21. Haas D, Chvatal R, Habelsberger A, Schimetta W, Wayand
W, Shamiyeh A, et al. Preoperative planning of surgery for
deeply infiltrating endometriosis using the ENZIAN
classification. Eur J Obstet Gynecol Reprod Biol. DOI:
10.1016/j.ejogrb.2012.10.012.
22. Stiftung Endometriose Forschung (SEF). Available at:
http://www.endometriose-sef.de.
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