text: Previews of the film began in March 2007 in the Chicago area. Under tight security to prevent piracy, WB had security guards patrol the aisles, looking for cell phone cameras or small recording devices, at a preview in Japan. The world premiere took place in Tokyo, Japan on 28 June 2007. MySpace users could bring copies of their online profiles to gain free admission to sneak previews in eight different cities across the country on 28 June 2007. The UK premiere took place on 3 July 2007 in London's Odeon Leicester Square, during which author J. K. Rowling made a public appearance. The US premiere took place on 8 July in Los Angeles. After the premiere, the three young stars of the film series, Radcliffe, Grint, and Watson, were honoured with a ceremony where their handprints, footprints, and "wandprints" were placed in the cement in front of Grauman's Chinese Theatre.


title: Harry Potter and the Order of the Phoenix (film)

text: Originally, Warner Bros. set the Australian release date as 6 September 2007, nearly two months after the majority of other release dates. However, after complaints from the Australian community, including a petition garnering 2,000 signatures the date was pulled back to 11 July 2007. The release dates of the film in the UK and US were also moved back, both from 13 July, to 12 and 11 July, respectively.


text: Even though the book is the longest in the series (over 700 pages), the film is 138 minutes long (2 hours and 18 minutes), the second shortest in the entire film series.


text: The DVDs included additional scenes, a feature showing a day in the life of Natalia Tena, who played Nymphadora Tonks, an A&E documentary about the films and books, and a featurette on film editing in "Phoenix". The DVD-ROM features a timeline and a sneak peek of the next film, "Harry Potter and the Half-Blood Prince" (2009). The HD DVD and Blu-ray contain additional features, such as the "in-movie experience", a video commentary in which members of Dumbledore's Army share their favourite moments from the production of the film, and "focus points" featurettes on how certain scenes of the film were made. The HD DVD also includes an exclusive feature called "community screening", which enables owners of the HD DVD to watch the film together over the Internet. "Order of the Phoenix" was the seventh best-selling DVD of 2007, with 10.14 million units. The high-definition DVDs had combined sales of 179,500 copies, with more units coming from the Blu-ray version.


text: There was also a third DVD with extras featuring a behind-the-scenes look at the sets of the movie. This can only be found in those purchased at Target stores (Future Shop in Canada) since it is a Target exclusive. The package included a one-time-only code that activated a digital copy of the film, which may be played on a computer with Windows Media Player. The digital copy is not playable on Macintosh or Apple Inc. iPod devices. This issue was partially addressed, with the film being made available on the iTunes Store in the UK but not the US.


text: The film opened to a worldwide 5-day opening of $333 million, the fourteenth-biggest opening of all time. In the United States, tickets for hundreds of midnight showings of the film, bought from online ticket-seller Fandango, were sold out, making up approximately 90% of the site's weekly ticket sales. In the US and Canada, midnight screenings (very early morning on 11 July) brought in $12 million from 2,311 midnight exhibitions making the showings "the most successful batch of midnight exhibitions ever". In one-night earnings, "Phoenix" is behind only "At World's End", which had debuted four hours earlier on its date. In studio documents leaked in July 2010, it was revealed the film "lost" Warner Bros. about $167 million.


text: In North America, "Phoenix" earned an additional $32.2 million on Wednesday, post-midnight showings, making it the biggest single-day Wednesday gross in box office history, with a total of $44.2 million from 4,285 theatres. That amount topped Sony Pictures' "Spider-Man 2", which held the record since 2004 with its $40.4 million take on a Wednesday, until this record was broken in 2009 by "" with $62 million. It was also the fifth-biggest opening day for a movie in history, at the time, surpassing "At World's End's" $42.9 million. It earned $1.9 million from a record-breaking 91 IMAX screens, the highest opening day ever for any IMAX day of the week, beating "Spider-Man 3's" $1.8 million. In the UK the result was similar. The film made £16.5 million during its opening 4-day run, breaking the UK box office record for the biggest 4-day opening weekend ever.


text: "Phoenix"s gross was at $292.4 million in the US and Canada, making it the fifth-highest-grossing film of 2007 in these regions, and at £49.2 million, or $101.4 million in the UK. Internationally, it has grossed $648 million, the seventh-highest grosser ever overseas, for a worldwide total of $942 million making it the second-highest-grossing film of the year closely behind ""s $960 million gross. It became the sixth-highest-grossing film in history at the time, the second-highest-grossing "Potter" film worldwide, and the second "Potter" film to break the $900 million mark, as well as the fourth-highest-grossing "Potter" film in the franchise behind "Harry Potter and the Deathly Hallows – Part 2"s $1.341 billion, "Harry Potter and the Philosopher's Stone"s $974 million, "Harry Potter and the Deathly Hallows – Part 1"s $960 million and the highest-grossing 2007 film in Australia and the UK. IMAX Corporation and Warner Bros. Pictures announced that the film has made over $35 million on IMAX screens, worldwide, with an impressive per-screen average of $243,000 making it the highest-grossing live-action IMAX release in history. In South Africa the film opened at number 1 with a total of $944,082.00, being screened at 87 theatres.


text: On review aggregator Rotten Tomatoes the film has an approval rating of based on reviews, with an average rating of . The site's critical consensus reads, "It's not easy to take the longest "Harry Potter" book and streamline it into the shortest HP movie, but director David Yates does a bang up job of it, creating an "Order of the Phoenix" that's entertaining and action-packed." On Metacritic, the film has a score of 71 out of 100, based on 37 critics, indicating "generally favourable reviews". Audiences surveyed by CinemaScore gave the film an average grade of "A−" on an A+ to F scale.


text: Roger Ebert gave the film 2.5 of 4 stars saying "Harry no longer has as much joy." The review by Charles Frederick of "The Telegraph" was headlined "Potter film is the best and darkest yet". Colin Bertram of the "New York Daily News" gave the film four out of four stars, calling it the best "Potter" film yet and wrote that "die-hard Potter addicts will rejoice that Yates has distilled J. K. Rowling's broad universe with care and reverence". Mark Adams of "The Sunday Mirror", while giving the film four out of five stars, called it "a dark and delicious delight [and] a must-see movie". Rene Rodriguez of "The Miami Herald" gave the film three stars out of four and wrote that the film "is the first installment in the soon-to-be series-of-seven that doesn't seem like just another spinoff capitalizing on the money-minting Harry Potter brand name. Instead, Phoenix feels like a real 'movie'".


text: Imelda Staunton's performance as Dolores Umbridge and Helena Bonham Carter's as Bellatrix Lestrange were widely acclaimed; Staunton was described as "coming close to stealing the show" by "The Guardian" and the "perfect choice for the part" and "one of the film's greatest pleasures" by "Variety". Bonham Carter was said to be a "shining but underused talent" by "The Times". "Variety" further praised Alan Rickman's portrayal of Severus Snape, writing that he "may have outdone himself; seldom has an actor done more with less than he does here". Newcomer Evanna Lynch, playing Luna Lovegood, also received good word from a number of reviewers, including the "New York Times", which declared her "spellbinding".


text: Peter Travers of "Rolling Stone" also lauded the three principal actors' achievements, especially Radcliffe: "One of the joys of this film is watching Daniel Radcliffe grow so impressively into the role of Harry. He digs deep into the character and into Harry's nightmares. It's a sensational performance, touching all the bases from tender to fearful". "Rolling Stone"s review also classified the film as better than the previous four instalments in the series, by losing the "candy-ass aspect" of the first two and "raising the bar" from the "heat and resonance" of the third and fourth. Peter Travers of "Rolling Stone" called the film "the best of the series so far, [with] the laughs, the jitters and the juice to make even nonbelievers wild about Harry".


text: Leo Lewis of "The Times" (London) expressed disappointment that the three main actors were not able to fully advance the emotional sides of their respective characters, weakening the film. The "San Francisco Chronicle" complained about a "lousy" storyline, alleging that the first twenty minutes of the film, when Harry is put on trial for performing magic outside of school and threatened with expulsion, but is cleared of all charges, did not advance the plot. Kirk Honeycutt of "The Hollywood Reporter" wrote that "Phoenix" is "quite possibly the least enjoyable of the [series] so far", and that despite "several eye-catching moments", "the magic – movie magic, that is – is mostly missing". The review also criticised the under use of the "cream of British acting", noting the brief appearances of Helena Bonham Carter, Maggie Smith, Emma Thompson, David Thewlis, Richard Griffiths, and Julie Walters.


text: Before it was released, "Order of the Phoenix" was nominated in a new category at the 2007 MTV Movie Awards, "Best Summer Movie You Haven't Seen Yet". On 26 August 2007, the film won the award for Choice Summer Movie – Drama/Action Adventure at the Teen Choice Awards.


text: The film was also nominated for several awards at the 2007 Scream Awards presented by Spike TV, in the categories of The Ultimate Scream, Best Fantasy Movie, and Best Sequel. Daniel Radcliffe was nominated in the Fantasy Hero categories, respectively. The film won for Best Sequel and Ralph Fiennes won for "Most Vile Villain". The film picked up three awards at the inaugural ITV National Movie Awards, taking Best Family Film, Best Actor for Radcliffe and Best Actress for Emma Watson. The film was one of ten nominees for a 2007 Hollywood Movie of the Year. It was also nominated for Best Live Action Family Film at the Broadcast Film Critics Association Awards and won the 2007 People's Choice Award for "Favorite Movie Drama". The production was also nominated for six awards at the 13th Empire Awards, organised by "Empire", including Best Film, David Yates won Best Director. Yates later received the BAFTA Britannia Award for Artistic Excellence in Directing for his four "Harry Potter" films, which includes "Order of the Phoenix".


text: Nicholas Hooper received a nomination for a World Soundtrack Discovery Award for his score to the film. Imelda Staunton was nominated in the "British Actress in a Supporting Role" category at the London Film Critics Circle Awards. At the 2008 BAFTA Awards, the film was nominated for "Best Production Design" and "Best Special Visual Effects". "Order of the Phoenix" was also nominated for the awards from the Art Directors Guild and Costume Designers Guild, and was awarded for "Outstanding Special Effects in a Motion Picture" by the Visual Effects Society out of six nominations.


text: The British Academy Children's Awards (BAFTA) nominated "Order of the Phoenix" for Best Feature Film in 2007 and the Hugo Awards nominated the film for Best Dramatic Presentation (Long Form) in 2008.


title: Endometriosis

text: Endometriosis is a disease of the female reproductive system in which cells similar to those in the endometrium, the layer of tissue that normally covers the inside of the uterus, grow outside the uterus. Most often this is on the ovaries, fallopian tubes, and tissue around the uterus and ovaries; in rare cases it may also occur in other parts of the body. Some symptoms include pelvic pain, heavy periods, pain with bowel movements, and infertility. Nearly half of those affected have chronic pelvic pain, while in 70% pain occurs during menstruation. Pain during sexual intercourse is also common. Infertility occurs in up to half of affected individuals. About 25% of individuals have no symptoms and 85% of those seen with infertility in a tertiary center have no pain. Endometriosis can have both social and psychological effects.


title: Endometriosis

text: The cause is not entirely clear. Risk factors include having a family history of the condition. The areas of endometriosis bleed each month (menstrual period), resulting in inflammation and scarring. The growths due to endometriosis are not cancer. Diagnosis is usually based on symptoms in combination with medical imaging; however, biopsy is the surest method of diagnosis. Other causes of similar symptoms include pelvic inflammatory disease, irritable bowel syndrome, interstitial cystitis, and fibromyalgia. Endometriosis is commonly misdiagnosed and people often report being incorrectly told their symptoms are trivial or normal. People with endometriosis see an average of seven physicians before receiving a correct diagnosis, with an average delay of 6.7 years between the onset of symptoms and surgically obtained biopsies, the gold standard for diagnosing the condition. This average delay places endometriosis at the extreme end of diagnostic inefficiency.


title: Endometriosis

text: Tentative evidence suggests that the use of combined oral contraceptives reduces the risk of endometriosis. Exercise and avoiding large amounts of alcohol may also be preventive. There is no cure for endometriosis, but a number of treatments may improve symptoms. This may include pain medication, hormonal treatments or surgery. The recommended pain medication is usually a non-steroidal anti-inflammatory drug (NSAID), such as naproxen. Taking the active component of the birth control pill continuously or using an intrauterine device with progestogen may also be useful. Gonadotropin-releasing hormone agonist (GnRH agonist) may improve the ability of those who are infertile to get pregnant. Surgical removal of endometriosis may be used to treat those whose symptoms are not manageable with other treatments.


title: Endometriosis

text: One estimate is that 10.8 million people are affected globally . Other sources estimate 6 to 10% of the general female population and 2 to 11% of asymptomatic women are affected. In addition, 11% of women in a general population have undiagnosed endometriosis that can be seen on magnetic resonance imaging (MRI). Endometriosis is most common in those in their thirties and forties; however, it can begin in girls as early as eight years old. It results in few deaths with unadjusted and age-standardized death rates of 0.1 and 0.0 per 100,000. Endometriosis was first determined to be a separate condition in the 1920s. Before that time, endometriosis and adenomyosis were considered together. It is unclear who first described the disease.


title: Endometriosis

text: Pain and infertility are common symptoms, although 20–25% of women are asymptomatic. Presence of pain symptoms are associated with the type of endometrial lesions as 50% of women with typical lesions, 10% of women with cystic ovarian lesions, and 5% of women with deep endometriosis do not have pain.


title: Endometriosis

text: A major symptom of endometriosis is recurring pelvic pain. The pain can range from mild to severe cramping or stabbing pain that occurs on both sides of the pelvis, in the lower back and rectal area, and even down the legs. The amount of pain a person feels correlates weakly with the extent or stage (1 through 4) of endometriosis, with some individuals having little or no pain despite having extensive endometriosis or endometriosis with scarring, while others may have severe pain even though they have only a few small areas of endometriosis. The most severe pain is typically associated with menstruation. Pain can also start a week before a menstrual period, during and even a week after a menstrual period, or it can be constant. The pain can be debilitating and result in emotional stress. Symptoms of endometriosis-related pain may include:


title: Endometriosis

text: Compared with patients with superficial endometriosis, those with deep disease appear to be more likely to report shooting rectal pain and a sense of their insides being pulled down. Individual pain areas and pain intensity appear to be unrelated to the surgical diagnosis, and the area of pain unrelated to the area of endometriosis.


title: Endometriosis

text: There are multiple causes of pain. Endometriosis lesions react to hormonal stimulation and may "bleed" at the time of menstruation. The blood accumulates locally if it is not cleared shortly by the immune, circulatory, and lymphatic system. This may further lead to swelling, which triggers inflammation with the activation of cytokines, which results in pain. Another source of pain is the organ dislocation that arises from adhesion binding internal organs to each other. The ovaries, the uterus, the oviducts, the peritoneum, and the bladder can be bound together. Pain triggered in this way can last throughout the menstrual cycle, not just during menstrual periods.


title: Endometriosis

text: Also, endometriotic lesions can develop their own nerve supply, thereby creating a direct and two-way interaction between lesions and the central nervous system, potentially producing a variety of individual differences in pain that can, in some cases, become independent of the disease itself. Nerve fibres and blood vessels are thought to grow into endometriosis lesions by a process known as neuroangiogenesis.


title: Endometriosis

text: About a third of women with infertility have endometriosis. Among those with endometriosis, about 40% are infertile. The pathogenesis of infertility is dependent on the stage of disease: in early stage disease, it is hypothesised that this is secondary to an inflammatory response that impairs various aspects of conception, whereas in later stage disease distorted pelvic anatomy and adhesions contribute to impaired fertilisation.


title: Endometriosis

text: Other symptoms include diarrhea or constipation, chronic fatigue, nausea and vomiting, migraines, low-grade fevers, heavy (44%) and/or irregular periods (60%), and hypoglycemia. There is an association between endometriosis and certain types of cancers, notably some types of ovarian cancer, non-Hodgkin's lymphoma and brain cancer. Endometriosis is unrelated to endometrial cancer. Rarely, endometriosis can cause endometrium-like tissue to be found in other parts of the body. Thoracic endometriosis occurs when endometrium-like tissue implants in the lungs or pleura. Manifestations of this include coughing up blood, a collapsed lung, or bleeding into the pleural space.


title: Endometriosis

text: Complications of endometriosis include internal scarring, adhesions, pelvic cysts, chocolate cysts of ovaries, ruptured cysts, and bowel and ureter obstruction resulting from pelvic adhesions. Endometriosis-associated infertility can be related to scar formation and anatomical distortions due to the endometriosis.


title: Endometriosis

text: Thoracic endometriosis can be associated with recurrent thoracic endometriosis syndrome at times of a menstrual period that includes catamenial pneumothorax in 73% of women, catamenial hemothorax in 14%, catamenial hemoptysis in 7%, and pulmonary nodules in 6%.


title: Endometriosis

text: A 20-year study of 12,000 women with endometriosis found that individuals under 40 who are diagnosed with endometriosis are 3 times more likely to have heart problems than their healthy peers.


title: Endometriosis

text: Endometriosis may increase about 1% or less chance of getting ovarian, breast and thyroid cancers in women compared with those without.


title: Endometriosis

text: It results in few deaths with unadjusted and age-standardized death rates of 0.1 and 0.0 per 100,000.


title: Endometriosis

text: Sciatic endometriosis also called catamenial or cyclical sciatica is a sciatica whose cause is endometriosis and whose incidence is unknown. Diagnosis is usually made by an MRI or CT-myelography.


title: Endometriosis

text: "Endometriosis is associated with an elevated risk of developing depression and anxiety disorders". Studies suggest this is partially due to the pelvic pain experienced by endometriosis patients.


title: Endometriosis

text: Endometriosis is a heritable condition that is influenced by both genetic and environmental factors. Children or siblings of people with endometriosis are at higher risk of developing endometriosis themselves; low progesterone levels may be genetic, and may contribute to a hormone imbalance. There is an approximate six-fold increased incidence in individuals with an affected first-degree relative.


title: Endometriosis

text: It has been proposed that endometriosis results from a series of multiple hits within target genes, in a mechanism similar to the development of cancer. In this case, the initial mutation may be either somatic or heritable.


title: Endometriosis

text: Individual genomic changes (found by genotyping including genome-wide association studies) that have been associated with endometriosis include 9 locis robustly replicated in various MNAs reaching genome-wide significance :


title: Endometriosis

text: There are many findings of altered gene expression and epigenetics, but both of these can also be a secondary result of, for example, environmental factors and altered metabolism. Examples of altered gene expression include that of miRNAs.


title: Endometriosis

text: Several studies have investigated the potential link between exposure to dioxins and endometriosis, but the evidence is equivocal and potential mechanisms are poorly understood. A 2004 review of studies of dioxin and endometriosis concluded that "the human data supporting the dioxin-endometriosis association are scanty and conflicting", and a 2009 follow-up review also found that there was "insufficient evidence" in support of a link between dioxin exposure and developing endometriosis. A 2008 review concluded that more work was needed, stating that "although preliminary work suggests a potential involvement of exposure to dioxins in the pathogenesis of endometriosis, much work remains to clearly define cause and effect and to understand the potential mechanism of toxicity".


title: Endometriosis

text: While the exact cause of endometriosis remains unknown, many theories have been presented to better understand and explain its development. These concepts do not necessarily exclude each other. The pathophysiology of endometriosis is likely to be multifactorial and to involve an interplay between several factors.


title: Endometriosis

text: The main theories for the formation of the ectopic endometrium-like tissue include retrograde menstruation, Müllerianosis, coelomic metaplasia, vascular dissemination of stem cells, and surgical transplantation were postulated as early as 1870. Each is further described below.


title: Endometriosis

text: The theory of retrograde menstruation (also called the "implantation theory" or "transplantation theory") is the most commonly accepted theory for the dissemination and transformation of ectopic endometrium into endometriosis. It suggests that during a woman's menstrual flow, some of the endometrial debris flow backward through the Fallopian tubes and into the peritoneal cavity, attaching itself to the peritoneal surface (the lining of the abdominal cavity) where it can proceed to invade the tissue as or transform into endometriosis. It is not clear at what stage the transformation of endometrium, or any cell of origin such as stem cells or coelomic cells (see those theories below), to endometriosis begins.


title: Endometriosis

text: Proofs in support of the theory is based on retrospective epidemiological studies that an association with endometrial implants attached to the peritoneal cavity, which would develop into endometrial lesions and retrograde menstruation; and the fact that animals like rodents and non-human primates whose endometrium is not shed during the estrous cycle don't develop naturally endometriosis contrary to animals that have a natural menstrual cycle like rhesus monkeys and baboons.


title: Endometriosis

text: Retrograde menstruation alone is not able to explain all instances of endometriosis, and additional factors such as genetics, immunology, stem cell migration, and coelomic metaplasia (see "Other theories" on this page) are needed to account for disseminated disease and why many individuals with retrograde menstruation are not diagnosed with endometriosis. In addition, endometriosis has shown up in people who have never experienced menstruation including cisgender men, fetuses, and prepubescent girls. Further theoretical additions are needed to complement the retrograde menstruation theory to explain why cases of endometriosis show up in the brain and lungs. This theory has numerous other associated issues.


title: Endometriosis

text: Researchers are investigating the possibility that the immune system may not be able to cope with the cyclic onslaught of retrograde menstrual fluid. In this context there is interest in studying the relationship of endometriosis to autoimmune disease, allergic reactions, and the impact of toxic materials. It is still unclear what, if any, causal relationship exists between toxic materials or autoimmune disease and endometriosis. There are immune system changes in people with endometriosis, such as an increase of macrophage-derived secretion products, but it is unknown if these are contributing to the disorder or are reactions from it.


title: Endometriosis

text: Endometriotic lesions differ in their biochemistry, hormonal response, immunology, inflammatory response when compared to endometrium. This is likely because the cells that give rise to endometriosis are a side population of cells. Similarly, there are changes in, for example, the mesothelium of the peritoneum in people with endometriosis, such as loss of tight junctions, but it is unknown if these are causes or effects of the disorder.


title: Endometriosis

text: In rare cases where imperforate hymen does not resolve itself prior to the first menstrual cycle and goes undetected, blood and endometrium are trapped within the uterus until such time as the problem is resolved by surgical incision. Many health care practitioners never encounter this defect, and due to the flu-like symptoms it is often misdiagnosed or overlooked until multiple menstrual cycles have passed. By the time a correct diagnosis has been made, endometrium and other fluids have filled the uterus and Fallopian tubes with results similar to retrograde menstruation resulting in endometriosis. The initial stage of endometriosis may vary based on the time elapsed between onset and surgical procedure.


title: Endometriosis

text: The theory of retrograde menstruation as a cause of endometriosis was first proposed by John A. Sampson.


title: Endometriosis

text: Endometriosis may spread to the cervix and vagina or to sites of a surgical abdominal incision, known as "scar endometriosis." Rectovaginal or bowel endometriosis affects approximately 5-12% of those with endometriosis, and can cause severe pain with bowel movements.


title: Endometriosis

text: Deep infiltrating endometriosis has been defined as the presence of endometrial glands and stroma infiltrating more than 5 mm in the subperitoneal tissue. The prevalence of DIE is estimated to be 1 to 2%. Deep endometriosis typically presents as a single nodule in the vesicouterine fold or in the lower 20 cm of the bowel. Deep endometriosis is often associated with severe pain.


title: Endometriosis

text: Rarely, endometriosis appears in extrapelvic parts of the body, such as the lungs, brain, and skin. "Scar endometriosis" can occur in surgical abdominal incisions. Risk factors for scar endometriosis include previous abdominal surgeries, such as a hysterotomy or cesarean section, or ectopic pregnancies, salpingostomy puerperal sterilization, laparoscopy, amniocentesis, appendectomy, episiotomy, vaginal hysterectomies, and hernia repair.


title: Endometriosis

text: Less commonly lesions can be found on the diaphragm or lungs. Diaphragmatic endometriosis is rare, almost always on the right hemidiaphragm, and may inflict the cyclic pain of the right scapula (shoulder) or cervical area (neck) during a menstrual period. Pulmonary endometriosis can be associated with a thoracic endometriosis syndrome that can include catamenial (occurs during menstruation) pneumothorax seen in 73% of women with the syndrome, catamenial hemothorax in 14%, catamenial hemoptysis in 7%, and pulmonary nodules in 6%.


title: Endometriosis

text: A health history and a physical examination can lead the health care practitioner to suspect endometriosis. There is a clear benefit for undergoing an ultrasound diagnostic procedure (TVUS) as a first step of testing for endometriosis.


title: Endometriosis

text: For many patients, there are significant delays in diagnosis. Studies show an average delay of 11.7 years in the United States. Patients in the UK have an average delay of 8 years and in Norway of 6.7 years. A third of women had consulted their GP six or more times before being diagnosed.


title: Endometriosis

text: The most common sites of endometriosis are the ovaries, followed by the Douglas pouch, the posterior leaves of the broad ligaments, and the sacrouterine ligaments.


title: Endometriosis

text: As for deep infiltrating endometriosis, TVUS, TRUS and MRI are the techniques of choice for non-invasive diagnosis with a high sensitivity and specificity.


title: Endometriosis

text: Laparoscopy, a surgical procedure where a camera is used to look inside the abdominal cavity, is the only way to accurately diagnose the extent and severity of pelvic/abdominal endometriosis. Laparoscopy is not an applicable test for extrapelvic sites such as umbilicus, hernia sacs, abdominal wall, lung, or kidneys.


title: Endometriosis

text: Reviews in 2019 and 2020 concluded that 1) with advances in imaging, endometriosis diagnosis should no longer be considered synonymous with immediate laparoscopy for diagnosis, and 2) endometriosis should be classified a syndrome that requires confirmation of visible lesions seen at laparoscopy in addition to characteristic symptoms.


title: Endometriosis

text: Laparoscopy permits lesion visualization unless the lesion is visible externally (e.g., an endometriotic nodule in the vagina) or is extra-abdominal. If the growths (lesions) are not visible, a biopsy must be taken to determine the diagnosis. Surgery for diagnoses also allows for surgical treatment of endometriosis at the same time.


title: Endometriosis

text: During a laparoscopic procedure lesions can appear dark blue, powder-burn black, red, white, yellow, brown or non-pigmented. Lesions vary in size. Some within the pelvis walls may not be visible, as normal-appearing peritoneum of infertile women reveals endometriosis on biopsy in 6–13% of cases. Early endometriosis typically occurs on the surfaces of organs in the pelvic and intra-abdominal areas. Health care providers may call areas of endometriosis by different names, such as implants, lesions, or nodules. Larger lesions may be seen within the ovaries as endometriomas or "chocolate cysts", "chocolate" because they contain a thick brownish fluid, mostly old blood.


title: Endometriosis

text: Frequently during diagnostic laparoscopy, no lesions are found in individuals with chronic pelvic pain, a symptom common to other disorders including adenomyosis, pelvic adhesions, pelvic inflammatory disease, congenital anomalies of the reproductive tract, and ovarian or tubal masses.


title: Endometriosis

text: Vaginal ultrasound has a clinical value in the diagnosis of endometrioma and before operating for deep endometriosis. This applies to the identification of the spread of disease in individuals with well-established clinical suspicion of endometriosis. Vaginal ultrasound is inexpensive, easily accessible, has no contraindications and requires no preparation. Healthcare professionals conducting ultrasound examinations need to be experienced. By extending the ultrasound assessment into the posterior and anterior pelvic compartments the sonographer is able to evaluate structural mobility and look for deep infiltrating endometriotic nodules noting the size, location and distance from the anus if applicable. An improvement in sonographic detection of deep infiltrating endometriosis will not only reduce the number of diagnostic laparoscopies, it will guide management and enhance quality of life.


title: Endometriosis

text: Use of MRI is another method to detect lesions in a non-invasive manner. MRI is not widely used due to its cost and limited availability, however, it has the ability to detect the most common form of endometriosis (endometrioma) with a sufficient accuracy.


title: Endometriosis

text: It is recommended for the patient to receive an anti-spasmodic agent (hyoscine butylbromide for example), a big glass of water (if bladder is empty), to undergo MRI scanning in supine position and applying abdominal strap for having a better image quality from the MRI.


title: Endometriosis

text: T1W with and without suppression of fat is recommended for endometriomas; meanwhile, sagittal, axial and oblique 2D T2W are recommended for deep infiltrating endometriosis.


title: Endometriosis

text: Surgically, endometriosis can be staged I–IV by the revised classification of the American Society of Reproductive Medicine from 1997. The process is a complex point system that assesses lesions and adhesions in the pelvic organs, but it is important to note staging assesses physical disease only, not the level of pain or infertility. A person with Stage I endometriosis may have a little disease and severe pain, while a person with Stage IV endometriosis may have severe disease and no pain or vice versa. In principle the various stages show these findings:


title: Endometriosis

text: In 2010, essentially all proposed biomarkers for endometriosis were of unclear medical use, although some appear to be promising. The one biomarker that has been in use over the last 20 years is CA-125. A 2016 review found that this biomarker was present in those with symptoms of endometriosis; and, once ovarian cancer has been ruled out, a positive CA-125 may confirm the diagnosis. Its performance in ruling out endometriosis is low. CA-125 levels appear to fall during endometriosis treatment, but it has not shown a correlation with disease response.


title: Endometriosis

text: Another review in 2011 identified several putative biomarkers upon biopsy, including findings of small sensory nerve fibers or defectively expressed β3 integrin subunit. It has been postulated a future diagnostic tool for endometriosis will consist of a panel of several specific and sensitive biomarkers, including both substance concentrations and genetic predisposition.


title: Endometriosis

text: A 2016 review of endometrial biomarkers for diagnosing endometriosis was unable to draw conclusions due to the low quality of the evidence.


title: Endometriosis

text: Immunohistochemistry has been found to be useful in diagnosing endometriosis as stromal cells have a peculiar surface antigen, CD10, thus allowing the pathologist go straight to a staining area and hence confirm the presence of stromal cells and sometimes glandular tissue is thus identified that was missed on routine H&E staining.


title: Endometriosis

text: The most common pain scale for quantification of endometriosis-related pain is the visual analogue scale (VAS); VAS and numerical rating scale (NRS) were the best adapted pain scales for pain measurement in endometriosis. For research purposes, and for more detailed pain measurement in clinical practice, VAS or NRS for each type of typical pain related to endometriosis (dysmenorrhea, deep dyspareunia and non-menstrual chronic pelvic pain), combined with the clinical global impression (CGI) and a quality of life scale, are used.


title: Endometriosis

text: Limited evidence indicates that the use of combined oral contraceptives is associated with a reduced risk of endometriosis, as is regular exercise and the avoidance of alcohol and caffeine.


title: Endometriosis

text: While there is no cure for endometriosis, there are two types of interventions; treatment of pain and treatment of endometriosis-associated infertility. In many cases, menopause (natural or surgical) will abate the process. In the reproductive years, endometriosis is merely managed: the goal is to provide pain relief, to restrict progression of the process, and to restore or preserve fertility where needed. In younger individuals, some surgical treatment attempts to remove endometriotic tissue and preserve the ovaries without damaging normal tissue.


title: Endometriosis

text: Pharmacotherapy for pain management can be initiated based on the presence of symptoms and examination and ultrasound findings that rule out other potential causes.


title: Endometriosis

text: In general, the diagnosis of endometriosis is confirmed during surgery, at which time ablative steps can be taken. Further steps depend on circumstances: someone without infertility can manage symptoms with pain medication and hormonal medication that suppresses the natural cycle, while an infertile individual may be treated expectantly after surgery, with fertility medication, or with IVF.


title: Endometriosis

text: A 2020 Cochrane systematic review found that for all types of endometriosis, "it is uncertain whether laparoscopic surgery improves overrall pain compared to diagnostic laparoscopy".


title: Endometriosis

text: Surgery, if done, should generally be performed laparoscopically (through keyhole surgery) rather than open. Treatment consists of the ablation or excision of the endometriosis, electrocoagulation, lysis of adhesions, resection of endometriomas, and restoration of normal pelvic anatomy as much as is possible. When laparoscopic surgery is used, small instruments are inserted through the incisions to remove the endometriosis tissue and adhesions. Because the incisions are very small, there will only be small scars on the skin after the procedure, and most individuals recover from surgery quickly and have a reduced risk of adhesions. Many endometriosis specialists believe that excision is the ideal surgical method to treat endometriosis.


title: Endometriosis

text: As for deep endometriosis, a segmental resection or shaving of nodules is effective but is associated with an important rate of complications which about 4,6% is major.


title: Endometriosis

text: Historically, a hysterectomy (removal of the uterus) was thought to be a cure for endometriosis in individuals who do not wish to conceive. Removal of the uterus may be beneficial as part of the treatment, if the uterus itself is affected by adenomyosis. However, this should only be done in combination with removal of the endometriosis by excision. If endometriosis is not also removed at the time of hysterectomy, pain may persist.


title: Endometriosis

text: Presacral neurectomy may be performed where the nerves to the uterus are cut. However, this technique is not usually used due to the high incidence of associated complications including presacral hematoma and irreversible problems with urination and constipation.


title: Endometriosis

text: The underlying process that causes endometriosis may not cease after a surgical or medical intervention. A study has shown that dysmenorrhea recurs at a rate of 30 percent within a year following laparoscopic surgery. Resurgence of lesions tend to appear in the same location if the lesions were not completely removed during surgery. It has been shown that laser ablation resulted in higher and earlier recurrence rates when compared with endometrioma cystectomy; and recurrence after repetitive laparoscopy was similar to that after the first surgery. Endometriosis can come back after hysterectomy and bilateral salpingo-oophorectomy. It has 10% recurrent rate.


title: Endometriosis

text: Endometriosis recurrence following conservative surgery is estimated as 21.5% at 2 years and 40-50% at 5 years.


title: Endometriosis

text: Risk of developing complications following surgery depend on the type of the lesion that has undergone surgery.


title: Endometriosis

text: 55% to 100% of individuals develop adhesions following pelvic surgery, which can result in infertility, chronic abdominal and pelvic pain, and difficult reoperative surgery. Trehan's temporary ovarian suspension, a technique in which the ovaries are suspended for a week after surgery, may be used to reduce the incidence of adhesions after endometriosis surgery.


title: Endometriosis

text: The overall effectiveness of manual physical therapy to treat endometriosis has not yet been identified.


title: Endometriosis

text: A 2021 meta-analysis found that GnRH analogues and combined hormonal contraceptives were the best treatment for reducing dyspareunia, menstrual and non menstrual pelvic pain. A 2018 Swedish systematic review found a large number of studies but a general lack of scientific evidence for most treatments. There was only one study of sufficient quality and relevance comparing the effect of surgery and non-surgery. Cohort studies indicate that surgery is effective in decreasing pain. Most complications occurred in cases of low intestinal anastomosis, while risk of fistula occurred in cases of combined abdominal or vaginal surgery, and urinary tract problems were common in intestinal surgery. The evidence was found to be insufficient regarding surgical intervention.


title: Endometriosis

text: The advantages of physical therapy techniques are decreased cost, absence of major side-effects, it does not interfere with fertility, and near-universal increase of sexual function. Disadvantages are that there are no large or long-term studies of its use for treating pain or infertility related to endometriosis.


title: Endometriosis

text: Surgery is more effective than medicinal intervention for addressing infertility associated with endometriosis. Surgery attempts to remove endometrium-like tissue and preserve the ovaries without damaging normal tissue. Receiving hormonal suppression therapy after surgery might be positive regarding endometriosis recurrence and pregnancy. In-vitro fertilization (IVF) procedures are effective in improving fertility in many individuals with endometriosis.


title: Endometriosis

text: During fertility treatment, the ultralong pretreatment with GnRH-agonist has a higher chance of resulting in pregnancy for individuals with endometriosis, compared to the short pretreatment.


title: Endometriosis

text: Preliminary research on mouse models showed that monoclonal antibodies, as well as inhibitors of MyD88 downstream signaling pathway, can reduce lesion volume. Thanks to that, clinical trials are being done on using a monoclonal antibody directed against IL-33 and using anakinra, an IL-1 receptor antagonist.


title: Endometriosis

text: Promising preclinical outcomes is pushing clinical trials into testing cannabinoid extracts, dichloroacetic acid and curcuma capsules.


title: Endometriosis

text: Determining how many people have endometriosis is challenging because definitive diagnosis requires surgical visualization through laparoscopic surgery. Criteria that are commonly used to establish a diagnosis include pelvic pain, infertility, surgical assessment, and in some cases, magnetic resonance imaging. An ultrasound can identify large clumps of tissue as potential endometriosis lesions and ovarian cysts but it is not effective for all patients, especially in cases with smaller, superficial lesions.


title: Endometriosis

text: These studies suggest that endometriosis affects approximately 11% of women in the general population. Endometriosis is most common in those in their thirties and forties; however, it can begin as early as 8 years old. Endometriosis is estimated to affect over 190 million women in their reproductive years.


title: Endometriosis

text: It chiefly affects adults from premenarche to postmenopause, regardless of race or ethnicity or whether or not they have had children. It is primarily a disease of the reproductive years. Incidences of endometriosis have occurred in postmenopausal individuals, and in less common cases, individuals may have had endometriosis symptoms before they even reach menarche.


title: Endometriosis

text: The rate of recurrence of endometriosis is estimated to be 40-50% for adults over a 5-year period. The rate of recurrence has been shown to increase with time from surgery and is not associated with the stage of the disease, initial site, surgical method used, or post-surgical treatment.


title: Endometriosis

text: Endometriosis was first discovered microscopically by Karl von Rokitansky in 1860, although the earliest antecedents may have stemmed from concepts published almost 4,000 years ago. The Hippocratic Corpus outlines symptoms similar to endometriosis, including uterine ulcers, adhesions, and infertility. Historically, women with these symptoms were treated with leeches, straitjackets, bloodletting, chemical douches, genital mutilation, pregnancy (as a form of treatment), hanging upside down, surgical intervention, and even killing due to suspicion of demonic possession. Hippocratic doctors recognized and treated chronic pelvic pain as a true organic disorder 2,500 years ago, but during the Middle Ages, there was a shift into believing that women with pelvic pain were mad, immoral, imagining the pain, or simply misbehaving. The symptoms of inexplicable chronic pelvic pain were often attributed to imagined madness, female weakness, promiscuity, or hysteria. The historical diagnosis of hysteria, which was thought to be a psychological disease, may have indeed been endometriosis. The idea that chronic pelvic pain was related to mental illness influenced modern attitudes regarding individuals with endometriosis, leading to delays in correct diagnosis and indifference to the patients' true pain throughout the 20th and into the 21st century.


title: Endometriosis

text: Hippocratic doctors believed that delaying childbearing could trigger diseases of the uterus, which caused endometriosis-like symptoms. Women with dysmenorrhea were encouraged to marry and have children at a young age. The fact that Hippocratics were recommending changes in marriage practices due to an endometriosis-like illness implies that this disease was likely common, with rates higher than the 5-15% prevalence that is often cited today. If indeed this disorder was so common historically, this may point away from modern theories that suggest links between endometriosis and dioxins, PCBs, and chemicals.


title: Endometriosis

text: The early treatment of endometriosis was surgical and included oophorectomy (removal of the ovaries) and hysterectomy (removal of the uterus). In the 1940s, the only available hormonal therapies for endometriosis were high-dose testosterone and high-dose estrogen therapy. High-dose estrogen therapy with diethylstilbestrol for endometriosis was first reported by Karnaky in 1948 and was the main pharmacological treatment for the condition in the early 1950s. Pseudopregnancy (high-dose estrogen–progestogen therapy) for endometriosis was first described by Kistner in the late 1950s. Pseudopregnancy as well as progestogen monotherapy dominated the treatment of endometriosis in the 1960s and 1970s. These agents, although efficacious, were associated with intolerable side effects. Danazol was first described for endometriosis in 1971 and became the main therapy in the 1970s and 1980s. In the 1980s GnRH agonists gained prominence for the treatment of endometriosis and by the 1990s had become the most widely used therapy. Oral GnRH antagonists such as elagolix were introduced for the treatment of endometriosis in 2018.


title: Endometriosis

text: The economic burden of endometriosis is widespread and multifaceted. Endometriosis is a chronic disease that has direct and indirect costs which include loss of work days, direct costs of treatment, symptom management, and treatment of other associated conditions such as depression or chronic pain. One factor which seems to be associated with especially high costs is the delay between onset of symptoms and diagnosis.


title: Endometriosis

text: Costs vary greatly between countries. Two factors that contribute to the economic burden include healthcare costs and losses in productivity. A Swedish study of 400 endometriosis patients found "Absence from work was reported by 32% of the women, while 36% reported reduced time at work because of endometriosis". An additional cross sectional study with Puerto Rican women, "found that endometriosis-related and coexisting symptoms disrupted all aspects of women's daily lives, including physical limitations that affected doing household chores and paid employment. The majority of women (85%) experienced a decrease in the quality of their work; 20% reported being unable to work because of pain, and over two-thirds of the sample continued to work despite their pain."


title: Endometriosis

text: There are a number of barriers that those affected face to receiving diagnosis and treatment for endometriosis. Some of these include outdated standards for laparoscopic evaluation, stigma about discussing menstruation and sex, lack of understanding of the disease, primary care physicians lack of knowledge, and assumptions about typical menstrual pain. On average, those later diagnosed with endometriosis waited 2.3 years after the onset of symptoms before seeking treatment and nearly three quarters of women receive a misdiagnosis prior to endometriosis. Self-help groups say practitioners delay making the diagnosis, often because they do not consider it a possibility. There is a typical delay of 7–12 years from symptom onset in affected individuals to professional diagnosis. There is a general lack of knowledge about endometriosis among primary care physicians. Half of general health care providers surveyed in a 2013 study were unable to name three symptoms of endometriosis. Health care providers are also likely to dismiss described symptoms as normal menstruation. Younger patients may also feel uncomfortable discussing symptoms with a physician.


title: Endometriosis

text: Race and ethnicity may play a role in how endometriosis affects one's life. Endometriosis is less thoroughly studied among Black people, and the research that has been done is outdated. Black people with endometriosis may face barriers in receiving care due to misconceptions about how Black people feel pain. Since pain is the primary symptom of endometriosis, this makes it increasingly possible for doctors to dismiss pain symptoms when their patient is Black. An inaccurate diagnosis is also more likely since Black women are at a higher risk for other related conditions such as uterine fibroids.


title: Endometriosis

text: Cultural differences among ethnic groups also contribute to attitudes toward and treatment of endometriosis, especially in Hispanic or Latino communities. A study done in Puerto Rico in 2020 found that health care and interactions with friends and family related to discussing endometriosis were affected by stigma. The most common finding was a referral to those expressing pain related to endometriosis as "changuería" or "changas", terms used in Puerto Rico to describe pointless whining and complaining, often directed at children.


title: Maitland Ward

text: Ashley Maitland Welkos (born February 3, 1977), known professionally as Maitland Ward, is an American actress and model. She made her acting debut as Jessica Forrester on the CBS soap opera "The Bold and the Beautiful" (1994–1996). Continuing to appear in film and television through the mid-2000s, she came to further prominence for playing Rachel McGuire on the sixth and seventh seasons of the ABC sitcom "Boy Meets World" (1998–2000). After retiring from mainstream acting in 2007, Ward began performing in pornographic films in 2019.


title: Maitland Ward

text: Ward starred as Jessica Forrester on "The Bold and the Beautiful", where she appeared from 1994 to 1996. She landed that role, which was her first acting role, when she was 16 and still a junior in high school. Ward had guest-starring roles on "USA High" and the seventh season of ABC's "Home Improvement"; and co-starred with Jay Thomas and Mario Lopez in the 1997 television film "Killing Mr. Griffin".


title: Maitland Ward

text: Her character of Rachel McGuire was added to "Boy Meets World" in 1998, at the beginning of the sixth season, as a main cast member. This role lasted until the series ended in 2000. After Ward's stint on "Boy Meets World", she appeared in the independent film "Dish Dogs", a romantic comedy in which she co-stars with Brian Dennehy, Matthew Lillard and Sean Astin. Later, she appeared in the 2004 comedy film "White Chicks" with Shawn and Marlon Wayans.


title: Maitland Ward

text: After retiring from mainstream acting, Ward began engaging in cosplay and making appearances at various comics conventions. Her first cosplay was a slave Princess Leia outfit; she was given the idea by photographers that she had worked with on the red carpet. She also appeared as Jessica 6 from "Logan's Run" and as Red Sonja. In recent years, she has also made comics-convention appearances wearing only body paint.


title: Maitland Ward

text: Beginning in mid-2013, Ward began posting nude and topless photographs of herself on Snapchat and Instagram, gaining a large following on both sites. In April 2016, she posted her first nude pictures to social media of her being body-painted for Luciano Paesani for a Los Angeles exhibition called "Living Art". In 2019, she announced on Instagram that she would be performing in an adult film entitled "Drive", a move described by "In Touch Weekly" as a "drastic career-shift". Ward received support from former "Boy Meets World" co-star Trina McGee.


title: Maitland Ward

text: In May 2019, Ward signed with adult talent agency Society 15. She stated that she had been approached by adult actress and director Kayden Kross and was "just floored" by the proposition of doing adult films. She told "In Touch Weekly", "It's been an evolution. It's all been my authentic journey because everything that I have done along the way is something I wanted to explore and do. I just did it publicly for my fans, that is the exhibitionist style of me." "Drive" was released online at the website Deeper.com on September 30, 2019.


title: Maitland Ward

text: Of her decision, Ward stated that she feared being typecast and believed that if she became a porn star, new fans would have an opportunity to discover her. Upon "Drive"'s release, Ward promised "more taboo stuff to come", and she subsequently appeared in multiple additional porn scenes released on Deeper.com. She has said that she did not believe in any stigma related to being a porn star. Conversely, she claimed that she regards her transition into adult films as a savvy business move.


title: Maitland Ward

text: A "Long Beach, California, native" according to "Life & Style", Ward married real estate agent Terry Baxter on October 21, 2006. The couple met on a set, and she credits their friendship and humor for the success of their relationship.


title: Maitland Ward

text: After getting married, Baxter and Ward moved to New York, where they still live. While they were there, Ward studied writing and screenwriting at New York University.


title: Mahjong

text: Mahjong or mah-jongg ( ) is a tile-based game that was developed in the 19th century in China and has spread throughout the world since the early 20th century. It is commonly played by four players (with some three-player variations found in parts of China, Japan, South Korea and Southeast Asia). The game and its regional variants are widely played throughout East and Southeast Asia and have also become popular in Western countries. The game has also been adapted into a widespread online entertainment. Similar to the Western card game rummy, Mahjong is a game of skill, strategy, and luck. To distinguish it from mahjong solitaire, it is sometimes referred to as mahjong rummy.


title: Mahjong

text: The game is played with a set of 144 tiles based on Chinese characters and symbols, although many regional variations may omit some tiles or add unique ones. In most variations, each player begins by receiving 13 tiles. In turn, players draw and discard tiles until they complete a legal hand using the 14th drawn tile to form four melds (or sets) and a pair (eye). A player can also win with a small class of special hands. While many variations of mahjong exist, most variations have some basic rules in common including how a piece is drawn and discarded, how a piece is robbed from another player, the use of suits (numbered tiles) and honors (winds and dragons), the basic kinds of melds allowed, how to deal the tiles and the order of play. Beyond these basic common rules, numerous regional variations exist which may have notably different criteria for legal melds and winning hands, radically different scoring systems and even elaborate extra rules. A group of players may introduce their own house rules which can notably change the feel of play.


title: Mahjong

text: In Chinese, the game was originally called ()meaning sparrowwhich is still used in some languages in southern China. It is said that the clacking of tiles during shuffling resembles the chattering of sparrows. It has also been suggested that the name came from an evolution of an earlier card game called Madiao from which mahjong tiles were adapted. Most Mandarin-speaking Chinese now call the game ("májiàng"). Its name is similar in other languages, except in Thai, where it is called ("phai nok krachok"), a calque meaning "sparrow cards".


title: Mahjong

text: There are many highly varied versions of mahjong both in rules and tiles used. "Old Hong Kong mahjong" uses the same basic features and rules as the majority of the different variations of the game. This form of mahjong uses all of the tiles of the most commonly available sets, includes no exotic complex rules, and has a relatively small set of scoring sets/hands with a simple scoring system. For these reasons Hong Kong mahjong is a suitable variation for the introduction of game rules and play and is the focus of this article.


title: Mahjong

text: Old Hong Kong mahjong is played with a standard set of 144 mahjong tiles (though cards may be used). Sets often include counters (to keep score), dice (to decide how to deal), and a marker to show who the dealer is and which round is being played. Some sets include racks to hold the tiles, especially if they are larger or smaller than standard tiles or have an odd shape. Mahjong sets originating from the United States, Japan or Southeast Asia will likely have extra tiles or specialized markings.


title: Mahjong

text: Suited tiles are divided into three suits and each are numbered from 1 to 9. The suits are bamboos, dots, and characters. There are four identical copies of each suited tile totaling 108 tiles.


title: Mahjong

text: The bamboo suit is also known as "sticks", "strings" or "bams" suit; the first tile usually has a bird (traditionally, a peacock or sparrow) instead of a single bamboo. The dots suit is also known as the "wheels", "circles", "coins", "stones", "marbles" or "balls" suit. The characters suit is also known as the "myriads", "cracks" or "numbers" suit since the top characters are numbers in the Chinese orthography, and the bottom characters (in traditional Chinese characters) are the Chinese orthography of "ten thousand".


title: Mahjong

text: There are two different sets of honors tiles: winds and dragons. The winds are east, south, west, and north, beginning with east. The dragons are red, green, and white. The white dragon has a blue or black frame on the face of the piece or in some sets is entirely blank. These tiles have no numerical sequence like the suited tiles (for example the bamboo pieces number 1 to 9). Like the suited tiles, there are four identical copies of each honors tile, for a total of 28 honors tiles.


title: Mahjong

text: There are two sets of bonus tiles: flowers and seasons. The flower and season tiles play a unique role in the mechanics of the game. When drawn, the bonus tile is not added into a player's hand but are instead set aside and kept near the player's other tiles for scoring purposes should they win the hand, and an extra tile is drawn in replacement of the bonus tile.


title: Mahjong

text: In addition, unlike the suited and honours tiles, there is only a single tile of each bonus tile, so there are a total of four flower and four season tiles in the set. The tiles have a different artistic rendering of a specific type of flower or season.


title: Mahjong

text: It is not necessary to know the names or the Chinese characters of each bonus tile, only the number, as this is associated with a specific direction, and the player receives bonus points when the bonus tile matches the seat direction. There is no relation between the bonus tile "bamboo" flower and the bamboo suit of suited tiles (e.g. 4 bamboo). In traditional Chinese culture, the Four Gentlemen are the plum (winter), orchid (spring), bamboo (summer), and chrysanthemum (autumn) which are regarded as the representative plants of those seasons, but people regard it as plum blossom (spring), orchid (summer), chrysanthemum (autumn) and bamboo (winter) now.


title: Mahjong

text: The dealer is chosen by various means. For example, each player throws dice with the highest count taking the dealer position, second-highest taking south etc. Or one player may place one tile of each wind face down and shuffle them. Each player randomly select one of these tiles and these tiles dictate their wind position. Each player sits down at their respective position (called the wind position) at the table in positions of an inverted compass: East is dealer, the right of the dealer is South, across is West, and the left is North. The order of play is traditionally counter-clockwise.


title: Mahjong

text: A match consists of four rounds, each representing a "prevailing wind", starting with East. Once the first round is completed, a second round begins with South as the prevailing wind, and so on. Wind position is significant in that it affects the scoring of the game. A mahjong set with winds in play will usually include a separate prevailing wind marker (typically a die marked with the wind characters in a holder).


title: Mahjong

text: In each round at least four hands are played, with each player taking the position of dealer. In the first hand of each round, Player 1 (winner of the dice toss) is East and therefore dealer. In the second hand, Player 2 takes the East position, shifting the seat winds amongst the players counterclockwise (though players do not physically move their chairs). This continues until all four players have been East (dealer). A marker is used to mark which player is East and often the round number. (In sets with racks, a rack may be marked differently to denote the dealer.)


title: Mahjong

text: Whenever a player in the East position (dealer) wins a hand, or if there is no winner (a draw or "goulash hand"), an extra hand is played with the same seating positions and prevailing wind as in the previous hand. This means that a match may potentially have no limit to the number of hands played (though some players will set a limit of three consecutive hands allowed with the same seat positions and prevailing wind).


title: Mahjong

text: All tiles are placed face down on the table and are shuffled. By convention all players should participate in shuffling using both hands moving the pieces around the table rigorously and loudly for a lengthy period. Tiles may get flipped up during this process and players should flip them facing down as soon as possible to avoid identifying the location of the revealed tiles.


title: Mahjong

text: Each player then stacks a row of 18 tiles, two tiles high in front of them (for a total of 36 tiles). Players then push each side of their stack together to form a square wall.


title: Mahjong

text: Regular players usually place their stacks in a slightly diagonal position (about 20 to 30 degrees anti-clockwise); the right end of their stack is pushed slightly further in to the centre of the table to meet almost the middle of the stack of the player on the right. This creates a smaller square wall the length of about half of each stack, with walls extended away from each corner of the square. The diagonally positioned stacks and a smaller square creates a bigger space for players' tiles and also makes an ergonomic position for drawing tiles from the stack.


title: Mahjong

text: The dealer throws three dice in the square wall and sums up the total. Counting anti-clockwise so that the dealer is 1 (or 5, 9, 13, 17), so that south (player to the right) is 2 (or 6, 10, 14, 18), etc., a player's quarter of the wall is chosen. Some house rules may use only two dice but have double throws to increase randomness. In the case of double throws, the player of the chosen wall makes the second throw.


title: Mahjong

text: Using the same total on the dice (or the total of the two throws), the player whose wall is chosen then counts the stacks of tiles from right to left. (For double throws, the count may extend to the left side player's stack.) This determines the location where the 'deck' of tiles is cut. Starting from the left of the stacks counted, the dealer draws four tiles for himself, and players in anti-clockwise order draw blocks of four tiles until all players have 12 tiles, so that the stacks decrease clockwise. Each player then draws one last tile to make a 13-tile hand. The tile to be drawn is always the topmost tile left of the cut.


title: Mahjong

text: Dealing does not have to be strictly this way and may be done quite differently based on house rules. Tiles may flip over when being dealt and players should agree in advance on how to deal with the problem. Solutions include having the dealer penalised points, shuffling the turned over piece back into the wall somehow, allowing the player to whom the tiles were dealt to take the piece or not (meaning the dealer must take it as his/her 14th piece), or other house rules.


title: Mahjong

text: Each player now sets aside any flowers or seasons they may have drawn and takes turns to draw replacement tiles from the wall in the anti-clockwise direction from the dealer. If a player gets any flowers or seasons tiles in the replacement draw, the players must wait for the next turn to draw replacement tiles.


title: Mahjong

text: The dealer draws a piece from the wall in clockwise direction, adding it to their hand. Typically, this draw is performed during the initial deal to speed up play. If this does not complete a legal hand, the dealer then discards a piece (throwing it into the middle of the wall with no particular order in mind).


title: Mahjong

text: Each player in turn, in counterclockwise direction, draws a tile from the wall; as long as the tile drawn is not one of the bonus tiles, the player proceeds to discard a tile (either the tile just drawn, or a tile in the hand) to maintain a hand of 13. The discarded tile is thrown into the centre and, if desired, the player announces out loud what the piece is. The other players have an opportunity to seize the discarded tile; if no one takes it, the turn continues to the next player. Play continues this way until one player has a legal winning hand and calls out the win (each region does this call differently--no Asian version uses the word "mahjong" to signal a win) while revealing their hand.


title: Mahjong

text: During play, each player's hand should always be 13 tiles (meaning in each turn a tile must be picked up and another discarded). The count of 13 tiles do not include any bonus tiles (flowers and seasons), which are set to the side, nor does it include the fourth added piece of a kong. If a player is seen to have fewer or more than 13 tiles in their hand outside of their turn they are penalised.


title: Mahjong

text: A winning hand consists of 14 tiles. Since players always have 13 tiles in their hand during play, they must win by either drawing a piece from the wall that completes a 14-tile hand ("winning from the wall") or claiming a discard from another player which completes a 14-tile hand ("winning by discard"). The winning hand is made of four "melds" (a specific pattern of three pieces) and the "eyes" (a pair of identical pieces). The exceptions to this rule are the special hands listed below.


title: Mahjong

text: Most players play with a table minimum, meaning a winning hand must score a minimum number of points (which can be seen in the scoring section). In Hong Kong mahjong the most common point set is three, but can be higher or lower depending on house rules.


title: Mahjong

text: Melds are groups of tiles within the player's hand, consisting of either a pong (three identical tiles), a kong (four identical tiles), a chow (three suited tiles all of the same suit, in numerical sequence), or eyes (two identical tiles needed in a winning hand). Melds may be formed by drawing a tile from the wall, or by seizing another player's discard. There are rules governing which player has priority for a discard, and whether the meld should be exposed (displayed to all players) or remain concealed, depending on the manner in which the meld is formed.


title: Mahjong

text: Whenever a player draws a flower or season, it is announced and then placed to the side (it is not considered a part of the 13-tile hand, but in the event that player wins, they may earn bonus points for them) and the last tile of the wall is drawn as a replacement tile so that the player has the 14 pieces needed before their discard. This may happen successively in a player's turn.


title: Mahjong

text: When a player discards a tile, other players may steal the tile to complete a meld. Stealing tiles has both advantages (quickly forming a winning hand and scoring extra points) and disadvantages (being forced to reveal part of one's hand to other players and not being able to change the meld once declared).


title: Mahjong

text: When a meld (pong, kong, or chow) is declared through a discard, the player must state the type of meld to be declared and expose the meld by placing the three (or four) tiles face up. The player must then discard a tile, and play continues to the right. If the player who melds a discard is not directly after the discarder (in order of play), one or two players will essentially miss their turn as play continues anti-clockwise from the player who declared the meld.


title: Mahjong

text: If multiple players call for a discarded tile, priority for the discard depends on the declared action of the player stealing the discard.


title: Mahjong

text: The act of winning a hand interrupts play to assess the validity of the hand won. Upon confirmation, the player is awarded the hand's value per the specific game's rule.


title: Mahjong

text: If at any point in the game a player can use another player's discard to complete a legal hand (and with the agreed minimum points), they declare a win and reveal their winning hand. This ends the hand, and scoring commences. If more than one player can use a discard to win the hand, multiple ways can handle the situation based on agreed table rules: The players might count the points they would win with the discard and the winner is the one with the higher score, the winner might simply be the player closest to the discarder in order of turn, or multiple players may be granted the win simultaneously.


title: Mahjong

text: Alternatively, a player may also win by drawing a tile that completes a legal hand. This is called "winning from the wall". In Hong Kong mahjong, winning from the wall doubles the number of base points each loser must pay.


title: Mahjong

text: Technically, the declaration for winning a hand may be done at any time. However, the player must have a complete and legal hand. Otherwise, the player is penalized. The penalty depends on table rules. The player may forfeit points to the other players. Another potential penalty is the player who called out the false win must play the rest of the hand with their tiles face up on the table so other players can see them (open hand). Some methods apply the penalty at the end of the entire game. Again, the table rules dictate the enforcement of the penalty.


title: Mahjong

text: A rarely occurring and high-scoring feature of Hong Kong mahjong is a move called robbing the kong. If a player declares a kong by adding a fourth piece to a melded pong but another player can use that piece to complete a hand, the completing player takes priority to win the hand and may steal that piece from the player who intended to declare the kong.


title: Mahjong

text: Below are two examples of winning hands. A winning hand must consist of four melds (pongs, kongs, or chows) and a pair (eyes) and must also score the agreed table minimum.


title: Mahjong

text: Most players include table variations in their games, of which some non-standard are included. The hands of "seven different pairs" and "13 orphans" are examples which do not have four melds and the eyes. They are described in more detail below.


title: Mahjong

text: If the dealer wins the hand, they will remain the dealer and an extra hand is played in addition to the minimum 16 hands in a match.


title: Mahjong

text: An extra hand is also played if there is no winner by the time all the tiles in the wall have been drawn. When there is no winner it is known as a "goulash hand". Depending on table rules, the winner of the next game may take an agreed number of points from each player, carrying over the points from the non-winning hand to the winning one. If there are two or three goulash hands in a row then the winner would collect a considerable number of points from each player on top of their scoring hand. Because extra hands may be played every time a dealer wins or if there is a goulash hand, a match of 16 hands can easily become a match of 20 or even much more.


title: Mahjong

text: As table rules add a large amount of flexibility for players, they can choose to disregard the rule of extra hands and pass on the dealership regardless of who wins or if it results in a goulash hand. This puts a maximum estimated limit on the game duration and provides some amount of predictability.


title: Mahjong

text: Players may agree on table rules if the pace of the game is brisk or leisurely. For brisk games players may agree that a couple seconds after a discard are allowed for a "window of opportunity" before the next player picks up from the wall. Usually it is agreed once the next player has waited the duration of the "window of opportunity" and draws a tile from the wall, the previous discard is lost and cannot be claimed.


title: Mahjong

text: Old Hong Kong scoring is relatively simple. There is only one winner (or if there is a draw the hand is replayed). The winner must have a legal hand that meets the minimum "faan" points agreed to in advance (not including any bonus points). Only the winner scores, the other players pay the winner various sums. After each hand ends, the winner counts all of his or her "faan" points.


title: Mahjong

text: A concealed meld is one that contains no tiles stolen from another player's discard. A concealed hand is one made up of only concealed melds. Many variations distinguish between a concealed hand (winning from the wall) and a semi concealed hand (the last tile is a stolen discard). In most mahjong variations having a concealed hand can be valuable in scoring. Hong Kong mahjong does not award concealed melds/hands as generously as others. Concealed hands only the case with a few limit hands or half-limit hands (thirteen orphans, heavenly gates, four concealed pongs) as well as a complete hand (seven pairs) and over several melds (three concealed pongs).


title: Mahjong

text: A winning hand must include an agreed minimum amount of "faan" value (often 3). Some examples of scoring include:


title: Mahjong

text: A player only scores a bonus "faan" for flowers or seasons if it is their own flower or season (East=1, South=2, West=3 and North=4) or if the player has all four flowers or all four seasons (scoring 5 "faan" in total).


title: Mahjong

text: The losers pay the winning player points based on several criteria and depending on whether the game is for fun or for money. How points are reckoned is agreed by players beforehand. For example, they can keep a tally, exchange chips, or pay one another with money. The "faan" value of a hand is converted into base points which are then used to calculate the points the losers pay the winner. The table is progressive, doubling the number of base points when reaching a certain "faan" point target. The following is the Old Hong Kong simplified table; for other tables, see Hong Kong mahjong scoring rules.


title: Mahjong

text: This table is based on play where 3 "faan" is the minimum needed in order to win with a legal hand. If a player has 3 "faan", then their hand is worth one base point. A winning hand with 9 "faan" is worth four base points. Losing players must give the winning player the value of these base points. The following special cases result in doubled base points:


title: Mahjong

text: If two of these criteria apply to any player, they must double and then redouble the points owed to the winner.


title: Mahjong

text: Hong Kong mahjong is essentially a payment system of doubling and redoubling, where winning from the wall adds great value to the final payment and where the dealer is highly rewarded or penalised if they win or lose.


title: Mahjong

text: In Hong Kong mahjong there are a series of "limit hands". These are exceptional hands, difficult to obtain and are very valuable in point scoring. As many table rules put a limit on the number of points a winner's hand can score, full limit hands score that maximum. Table rules dictate if these rare and special hands are allowed, which ones, and the limit for scoring. A common scoring limit is 64 points, which is the highest base points doubled twice. A winner receives the scoring limit from each player without any doubling.


title: Mahjong

text: Some limit hands by necessity must be completely concealed (not discards used) or semi-concealed (the only discard used is the one needed to win). This includes the 13 orphans, 4 concealed pongs, heavenly hand and earthly hand. It is usually expected that the heavenly gates hand be concealed or semi-concealed. As for the dragon limit hands and the great winds, table rules dictate whether the hand must be concealed or not. Some table rules claim that a semi-concealed hand (winning from a discard) scores a half-limit.


title: Mahjong

text: Some groups also play with the "great flowers" rule. If a player picks up all four flowers and all four seasons during their hand, they instantly win the hand and receive the maximum points from all of the players. This is exceptionally rare.


title: Mahjong

text: Variations may have far more complicated scoring systems, add or remove tiles, and include far more scoring elements and limit hands.


title: Mahjong

text: In many places, players often observe one version and are either unaware of other variations or claim that different versions are incorrect. In mainland China alone, there are over thirty variants. Many variations today differ only by scoring:


title: Mahjong

text: Mahjong playing surfaces are typically square and small enough to be within arm's length of all equipment. The edges are raised to prevent tiles from sliding off and the surface is covered in felt to limit wear on the tiles. Automatic dealing tables, often used for high stakes playing and tournaments, are able to shuffle tiles, build walls, and randomize dice. It is an elaborate device built into a table which uses two alternating sets of tiles. It prepares one wall while the players play one hand. After the hand is finished the tiles are dropped into the table and a new wall raises upwards.


title: Mahjong

text: There are variations that feature specific use of tiles. Some three-player versions remove the North wind and one Chinese provincial version has no honors. Korean mahjong removes the bamboo suit or at least its numbers 2–8 so that terminals can be used. Japanese mahjong rarely uses flowers or seasons. The seasons are removed in Korean mahjong, while many Southeast Asian sets have more flower series.


title: Mahjong

text: Some mahjong variants accept wildcard tiles. The wildcard tiles are decided at the beginning of the game by choosing one random tile. The wild card could be the immediately following tile on the wall, after distributing tiles to all players, or it could also be separately decided by a dice throw. Wildcard tiles cannot be discarded and can only replace tiles in chows. Wildcard tiles cannot replace tiles in pongs and kongs. For example, if a character 4 is chosen, then character 4 and the next sequential tile, character 5, can be used as wild cards in this round. (When the wildcard indicator is chosen and exposed, only 3 tiles remain of the same denomination, so the next tile in the suit will also be used as a wildcard, adding to 7 wildcard tiles for 4 players.) Also, if a tile numbered 9 is the indicator, the suits circle back to 1, after 9. Thus, the number 9 and 1 are wild cards.


title: Mahjong

text: A feature of several variations of mahjong, most notably in American mahjong, is the notion of some number of Joker tiles. They may be used as a wild card: a substitute for any tile in a hand, or, in some variations, only tiles in melds. Another variation is that the Joker tile may "not" be used for melding. Depending on the variation, a player may replace a Joker tile that is part of an exposed meld belonging to any player with the tile it represents.


title: Mahjong

text: Rules governing discarding Joker tiles also exist; some variations permit the Joker tile to take on the identity of any tile, and others only permit the Joker tile to take on the identity of the previously discarded tile (or the absence of a tile, if it is the first discard).


title: Mahjong

text: Joker tiles may or may not affect scoring, depending on the variation. Some special hands may require the use of Joker tiles (for example, to represent a "fifth tile" of a certain suited or honor tile).


title: Mahjong

text: Japanese rule sets discourage the use of flowers and seasons. Korean rules and three-player mahjong in the Korean/Japanese tradition use only flowers. In Singapore and Malaysia an extra set of bonus tiles of four animals are used. The rule set includes a unique function in that players who get two specific animals get a one-time immediate payout from all players. In Taiwanese mahjong, getting all eight flowers and seasons constitutes an automatic win of the hand and specific payout from all players.


title: Mahjong

text: These animal tiles are used in Thailand, Malaysia, Singapore and local variations. They represent the cat, mouse, rooster and centipede. Like flower tiles, they also function as bonus tiles. However, as they have no corresponding seat position, any player who draws one of these gets a bonus point.


title: Mahjong

text: All tiles are placed face down and shuffled. Each player then stacks a row of tiles two tiles high in front of them, the length of the row depending on the number of tiles in use:


title: Mahjong

text: Depending on the variation, two or three dice are usually used to decide what part of the wall to start dealing from. They are six-sided dice, traditionally but not necessarily Chinese dice with red one and four pips.


title: Mahjong

text: The dealer marker is a round or square object that the dealer places to the side to remind players who the dealer is. The wind marker may be used which indicates the current prevailing wind. In some cases the dealer marker and the wind marker are represented by one large marker, usually a small wheel where one can swivel the outer circle to indicate the prevailing wind (which the dealer holds onto), a cube with the four winds placed onto four of the sides which can be placed in a hollow square (the dealer holds onto it), or a cylinder locked into frame which can be rolled to expose the wind on the top. Japanese mahjong, especially in a gambling environment, may optionally use four yakitori markers to indicate which players have not won a hand yet and has to pay a penalty.


title: Mahjong

text: There are a variety of counting pieces used in different countries. They range from Chinese or Japanese counting sticks (thin sticks with various dots on them to represent various points), jetons, play money, paper and pencil, or various apps on touchscreen devices used to calculate and keep scores.


title: Mahjong

text: Japanese and Korean mahjong have some special rules. A player cannot win by a discard if that player had already discarded that piece, where players' discards are kept in neat rows in front of them. Players may declare ready, meaning that they need one tile to win, cannot change their hand and win extra points if they win. Some rules may replace some of the number 5 tiles with red tiles, as they can earn more points. Korean mahjong does not allow melded (stolen) chows.


title: Mahjong

text: Taiwanese mahjong adds three tiles to a hand requiring a 5th set to be formed, making a clean hand or all-pong hand very difficult to procure.


title: Mahjong

text: American mahjong has distinctive game mechanics and the article on American mahjong details these. Some differences include many special patterns, a different scoring system and the use of jokers and five-of-a-kind.


title: Mahjong

text: In the American variations it is required that, before each hand begins, a Charleston be enacted. In the first exchange, three tiles are passed to the player on one's right; in the next exchange, the tiles are passed to the player opposite, followed by three tiles passed to the left. If all players are in agreement, a second Charleston is performed; however, any player may decide to stop passing after the first Charleston is complete. The Charleston is followed by an optional pass to the player across of one, two, or three tiles. The Charleston, a distinctive feature of American mahjong, may have been borrowed from card games such as Hearts.


title: Mahjong

text: Many variations have specific hands, some of which are common while some are optional depending on regions and players. One example is the Pure Green hand made of chows or pongs using 2, 3, 4, 6, 8 of bamboo and green dragon.


title: Mahjong

text: When a hand is one tile short of winning (for example: , waiting for: , , or , as can be the eyes), the hand is said to be a ready hand, or more figuratively, "on the pot". The player holding a ready hand is said to be "waiting" for certain tiles. It is common to be waiting for two or three tiles, and some variations award points for a hand that is waiting for one tile. In 13-tile mahjong, the largest number of tiles for which a player can wait is 13 (the "thirteen wonders", or "13 orphans", a nonstandard special hand). Ready hands must be declared in some variations of mahjong, while other variations prohibit the same.


title: Mahjong

text: Some variations of mahjong, most notably Japanese and Korean ones, allow a player to declare . A declaration of "rīchi" is a promise that any tile drawn by the player is immediately discarded unless it constitutes a win. Standard requirements for "rīchi" are that the hand be "closed" or have no melds declared (other than a concealed kong) and that players already have points for declaration of "rīchi". A player who declares "rīchi" and wins usually receives a point bonus for their hand directly, and a player who won with "rīchi" also has the advantage to open the inner dora which leads to higher possibilities to match such a card, thus has more chance to grant additional bonus. However, a player who declares "rīchi" and loses is usually penalised in some fashion. Declaring a nonexistent "rīchi" is also penalised in some way.


title: Mahjong

text: In some variations, a situation in which all four players declare a "rīchi" is an automatic drawn game, as it reduces the game down to pure luck, i.e., who gets their needed tile first.


title: Mahjong

text: If only the dead wall remains (or if no dead wall exists and the wall is depleted) and no one has won, the hand is drawn or "goulashed". A new hand begins, and depending on the variant, the Game Wind may change. For example, in most playing circles in Singapore, if there is at least one kong when the hand is a draw, the following player of the dealer becomes the next dealer; otherwise, the dealer remains dealer.


title: Mahjong

text: Japanese mahjong has a special rule called sanchahō, which is, if three players claim the same discard in order to win, the hand is drawn. One reason for this is that there are cases in which bars of 1,000 points for declaring "rīchi" cannot be divided by three. The rule is treated the same as "abortive draws".


title: Mahjong

text: In Japanese mahjong, rules allow abortive draws to be declared while tiles are still available. They can be declared under the following conditions:


title: Mahjong

text: Scoring in mahjong involves points, with a monetary value for points agreed upon by players. Although in many variations scoreless hands are possible, many require that hands be of some point value in order to win the hand.


title: Mahjong

text: While the basic rules are more or less the same throughout mahjong, the greatest divergence between variations lies in the scoring systems. Like the rules, there is a generalized system of scoring, based on the method of winning and the winning hand, from which Chinese and Japanese base their roots. American mahjong generally has greatly divergent scoring rules, as well as greatly divergent general rules.


title: Mahjong

text: Because of the large differences between the various systems of scoring (especially for Chinese variants), groups of players will often agree on particular scoring rules before a game.


title: Mahjong

text: Points (terminology of which differs from variation to variation) are obtained by matching the winning hand with different criteria scoring different values. The points obtained may be modified into scores for each player using some (typically exponential) functions. Some criteria may be also in terms of both points and score.


title: Mahjong

text: In many variations the dealer receives no scoring bonus and does not maintain their turn by winning or a dead hand.


title: Mahjong

text: In classical mahjong all players score points. Points are given for sets and hand composition and winning bonuses, doubled and redoubled for basic patterns. Sometimes a loser may score more points than a winner. Japanese mahjong has a complex scoring system with several stages of scoring, rules and exceptions, evening out scores and bonus points at the end of a match. Korean mahjong has a simple scoring system where only winner scores without any form of doubling.


title: Mahjong

text: Some variations give points for concealed hands, in which case no melds are made except by winning on a discard.


title: Mahjong

text: A single player game employs the tiles of mahjong, usually played on computers or devices. Gameplay is entirely unrelated to mahjong or its variations and is a recent invention. A two-player version was published by Nintendo. The game involves stacking tiles face up in various elaborate patterns and removing uncovered matching tiles at the end of rows.


title: Mahjong

text: In 1998, in the interest of dissociating illegal gambling from Mahjong, the China State Sports Commission published a new set of rules, now generally referred to as Chinese Official rules or International Tournament rules (see Guobiao Majiang). The principles of the new, wholesome Mahjong are no gambling, no drinking, and no smoking. In international tournaments, players are often grouped in teams to emphasize that Mahjong from now on is considered a sport.


title: Mahjong

text: The new rules are highly pattern-based. The rulebook contains 81 combinations, based on patterns and scoring elements popular in classic and modern regional Chinese variants; some table practices of Japan have also been adopted. Points for flower tiles (each flower is worth one point) may not be added until the player has scored eight points. The winner of a game receives the score from the player who discards the winning tile, plus eight basic points from each player; in the case of "zimo" (self-drawn win), they receive the value of this round plus eight points from all players.


title: Mahjong

text: The new rules were first used in an international tournament in Tokyo, where, in 2002, the first global tournament in mahjong was organized by the Mahjong Museum, the Japan Mahjong Organizing Committee, and the city council of Ningbo, China. One hundred players participated, mainly from Japan and China, but also from Europe and the United States. Mai Hatsune, from Japan, became the first world champion. The following year saw the first annual China Mahjong Championship, held in Hainan; the next two annual tournaments were held in Hong Kong and Beijing. Most players were Chinese; players from other nations attended as well.


title: Mahjong

text: In 2005, the first Open European Mahjong Championship was held in the Netherlands, with 108 players. The competition was won by Masato Chiba from Japan. The second European championship in Copenhagen (2007) was attended by 136 players and won by Danish player Martin Wedel Jacobsen. The first Online European Mahjong Championship was held on the Mahjong Time server in 2007, with 64 players, and the winner was Juliani Leo, from the U.S., and the Best European Player was Gerda van Oorschot, from the Netherlands. The Third Open European Mahjong Championship 2009 at Baden/Vienna, Austria, was won by Japanese player Koji Idota, while runner-up Bo Lang from Switzerland became European Champion. There were 152 participants.


title: Mahjong

text: In 2006, the World Mahjong Organization (WMO) was founded in Beijing, China, with the cooperation of, amongst others, the Japan Mahjong Organizing Committee (JMOC) and the European Mahjong Association (EMA). This organization held its first World Mahjong Championship in November 2007 in the Chinese town of Chengdu, attended by 144 participants from all over the world. It was won by Li Li, a Chinese student at Tsinghua University. The next World Championship took place in Utrecht, the Netherlands, 27 to 29 August 2010.


title: Mahjong

text: Other major international tournaments include the Mahjong International League's World Mahjong Sports Games and the privately sponsored World Series Of Mahjong.


title: Mahjong

text: American mahjong tournaments are held in virtually every state—the largest is in Las Vegas, Nevada, twice a year, and in Atlantic City, New Jersey, by Mah Jongg Madness (MJM), and an annual cruise is hosted by the National Mah Jongg League and MJM. MJM tournaments host between 150 and 500 participants at these larger events; there are several smaller-scale, but equally successful, tournaments held annually by other hosts. Prize pools are based on the number participating. Rules are based on the National Mah Jongg League standard rules.


title: Mahjong

text: Mahjong is based on draw-and-discard card games that were popular in 18th and 19th century China, some of which are still popular today. They were played with a stripped deck of money-suited cards. Each deck is divided into three suits of Cash or coins, Strings of cash, and Myriads of strings. There are nine ranks in each suit. In addition, there are three wild cards: Red flower, White flower, and Old thousand. Depending on the game, there are multiple copies of each card.


title: Mahjong

text: Games scholar David Parlett has written that the Western card games Conquian and Rummy share a common origin with Mahjong. All these games involve players drawing and discarding tiles or cards to make melds. Khanhoo is an early example of such a game. The most likely ancestor to Mahjong was "pènghú" which was played with 120 or 150 cards. During the late 19th century, "pènghú" was used interchangeably with "máquè" in both card and tile form.


title: Mahjong

text: It is not known when the conversion from cards to tiles took place precisely but it most likely occurred in the middle of the 19th century. The earliest surviving tile sets date to around 1870 and were acquired in Fuzhou, Shanghai, and Ningbo. These sets differ from modern ones in several ways. In the Glover sets, there were no "flower" and "fā" ("green dragon") tiles. In their place were "king" tiles for heaven, earth, man, and harmony and also for each of the 4 "winds" which may have acted as bonus tiles. In the contemporaneous Himly set, there were no "zhōng" ("red dragon") tiles either. Instead there were the wild cards known as Cash Flower, String Flower, and Myriad Flower plus an additional tile, the king of everything. These early jokers are still found in the Vietnamese and Thai sets. They may have been removed as the tiles share the same titles as the leaders of the Taiping Rebellion (1850–1864). For example, Hong Xiuquan was the self-styled "Heavenly King of Great Peace" and his top subordinates were called east king, south king, west king, and north king.


title: Mahjong

text: The ban on gambling after the founding of the People's Republic in 1949 led to a decline in playing. The game itself was banned during the Cultural Revolution (1966–1976). Today, it is a favorite pastime in China and other Chinese-speaking communities.