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Current clinical staging/grading schemes of endometriosis show poor correlation with clinical symptoms and histopathological confirmation is only in half of the clinically suspected endometriosis. In this study, done over an 8–year period, several histological features were analysed including an attempt to grade the severity of endometriosis histologically based on the number of  foci  per low power field. The components in each focus, the phasing of the glands and  stroma , the type of glands (endometrial type or undifferentiated type), and  stromal  features were all analysed. This study attempts to histologically grade endometriosis while relating it to the clinical manifestations and anatomical location. Eighty cases of endometriosis were included. Most common clinical presentation was cyclical pain ( n  = 62) and the most common anatomical location was  adnexa  ( n  = 50). Histologically, severe endometriosis (&gt;3  foci ) was seen in 37 cases. The components were mixed in 68 cases. Well-differentiated glandular pattern was typical ( n  = 54), while 6 cases had undifferentiated. Proliferative phase was seen in 38 cases. Fibrosis and inflammation were present in 29 and 42 cases, respectively. Significant vascular proliferation and plasma cell infiltrate was noted ( n  = 35). The severe grade was significantly associated with fibrosis ( p  = 0.03) and inflammation ( p  = 0.014). Endometriotic foci, unlike eutopic endometrium, shows significant plasma cell infiltrate and vascular proliferation.IMPACT STATEMENTWhat is already known on this subject?  Endometriosis, a chronic inflammatory condition in reproductive age group women. The currently used clinical staging and grading systems show poor correlation with patient symptoms and treatment outcomes. Endometriosis with classical histopathological features pose no diagnostic difficulty, however, there is poor concordance with histopathology. Atypical endometriosis is proposed as potential precursor for endometriosis related neoplasms, however, it remains as a controversial entity.What do the results of this study add?  The study identifies the uncommon histological patterns which may be encountered in biopsy samples from clinically identified endometriotic lesions. The recognition of these patterns will reduce clinico-pathological discrepancies. In keeping with the other grading systems, attempts at histological grading did not show any correlation with location or patient symptoms. Atypical features were seen only in two cases and was likely to be reactive in nature.What are the implications of these findings for clinical practice and/or further research?  Undifferentiated glandular pattern is often a under-recognized histological pattern. Histological grading of severity was a novel attempt to correlate with clinical parameters. Significant plasma cell infiltrate and vascular proliferation in endometriotic foci, underscores the quest for novel therapeutic targets. This study suggests that the use of non-invasive diagnostic methods like fibroscan/inflammatory markers to clinically identify severe disease should be investigated further. What is already known on this subject?  Endometriosis, a chronic inflammatory condition in reproductive age group women. The currently used clinical staging and grading systems show poor correlation with patient symptoms and treatment outcomes. Endometriosis with classical histopathological features pose no diagnostic difficulty, however, there is poor concordance with histopathology. Atypical endometriosis is proposed as potential precursor for endometriosis related neoplasms, however, it remains as a controversial entity. What do the results of this study add?  The study identifies the uncommon histological patterns which may be encountered in biopsy samples from clinically identified endometriotic lesions. The recognition of these patterns will reduce clinico-pathological discrepancies. In keeping with the other grading systems, attempts at histological grading did not show any correlation with location or patient symptoms. Atypical features were seen only in two cases and was likely to be reactive in nature. What are the implications of these findings for clinical practice and/or further research?  Undifferentiated glandular pattern is often a under-recognized histological pattern. Histological grading of severity was a novel attempt to correlate with clinical parameters. Significant plasma cell infiltrate and vascular proliferation in endometriotic foci, underscores the quest for novel therapeutic targets. This study suggests that the use of non-invasive diagnostic methods like fibroscan/inflammatory markers to clinically identify severe disease should be investigated further.

Histotyping and grading of endometriosis and its association with clinico-pathological parameters