Towards a uniform classification of endometriosis: a comparative review and evidence mapping of current classification systems

Purpose To compare current endometriosis classification systems across clinically relevant domains and to identify which components may be used for a single internationally accepted classification.

A PubMed search was performed up to December 31, 2025, to identify publications on the revised American Society for Reproductive Medicine classification (rASRM) and endometriosis classifications introduced after 2000 (#Enzian, AAGL, EFI, UBESS, dPEI, Endo-Stage MRI, NMS-E, VNESS, FOATIaRVS, Chapron), excluding case reports. The full classification names as well as their abbreviations were used as search terms. The included systems were evaluated across pre-defined domains: descriptive anatomical mapping, pain, fertility, quality of life, surgical complexity, surgical duration, complication risk, non-invasive applicability, treatment guidance, disease progression, postoperative recurrence, and reproducibility.

No currently available classification performed well across all domains. #Enzian provided the most comprehensive anatomical-descriptive framework. EFI remained the best-validated tool for predicting spontaneous conception after surgery. AAGL, UBESS, dPEI, and Endo-Stage MRI were most informative for operative complexity and surgical risk stratification. In contrast, correlations with pain, quality of life, disease progression, and treatment response were generally weak or inconsistent across systems. Evidence for recurrence prediction was limited, and reproducibility varied depending on the system and clinical setting.

Current endometriosis classifications remain purpose-specific and clinically fragmented. Rather than replacing one imperfect system with another, future progress will likely depend on a modular framework combining a robust anatomical-descriptive backbone with validated domain-specific overlays. Among existing systems, the modular #Enzian classification appears to offer the most promising structural basis for such further development. Similar content being viewed by others Funding Open access funding provided by Johannes Kepler University Linz. Author information Authors and Affiliations Corresponding author Ethics declarations Conflict of interest Simon-Hermann Enzelsberger and Peter Oppelt declare that they have no conflict of interest regarding the manuscript. Ethical approval Not applicable (review). Consent to participate Not applicable. Consent for publication Not applicable. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Supplementary Information Below is the link to the electronic supplementary material. Rights and permissions Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. About this article Cite this article Enzelsberger, SH., Oppelt, P. Towards a uniform classification of endometriosis: a comparative review and evidence mapping of current classification systems. Arch Gynecol Obstet (2026). https://doi.org/10.1007/s00404-026-08563-4 Received: Accepted: Published: DOI: https://doi.org/10.1007/s00404-026-08563-4