The AGCES Classification System for Endometriosis: Integrating Adenomyosis with Genital and Extragenital Staging—An Expert Consensus Framework from the American & Global College of Endometriosis Specialists (AGCES)

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Abstract
Background: Current endometriosis classification systems have important limitations in accurately describing total disease burden and predicting clinical outcomes. Existing staging frameworks often fail to integrate adenomyosis and do not adequately distinguish between genital and extragenital disease involvement. The aim of this article was to introduce the AGCES (American & Global College of Endometriosis Specialists) classification system, a novel framework designed to provide a more comprehensive and clinically meaningful approach to staging endometriosis. Methods: The AGCES classification system was developed through an expert consensus process involving scientific members of the American & Global College of Endometriosis Specialists (AGCES), informed by extensive surgical experience on thousands of endometriosis surgeries, synthesis of published evidence on disease pathophysiology and anatomical distribution, and systematic analysis of the limitations of existing classification systems (rASRM, ENZIAN, AAGL, EFI). Results: The framework integrates adenomyosis as a component of endometriosis staging and separates genital and extragenital disease into independent staging categories. Disease burden is reported using three parallel components representing adenomyosis (A), genital endometriosis (G), and extragenital endometriosis (E). A standardized operative reporting template and digital implementation through web-based applications were also developed to support clinical use. Conclusions: The AGCES classification system introduces a novel approach to endometriosis staging by integrating adenomyosis and separating genital and extragenital disease components. This framework provides a more complete assessment of disease burden and has the potential to improve clinical documentation, surgical planning, and research standardization in endometriosis care.

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