Treatment of endometriosis: a review with comparison of 8 guidelines

Key points

Overview

Endometriosis, the presence of endometrial-like tissue outside the uterus, affects about 10% of women of reproductive age. This review of guidelines available by September 2020 summarizes how eight guidelines approach the surgical and medical treatment of endometriosis-associated pain and infertility. The main finding is agreement on first-line hormonal therapy and laparoscopic surgery, with discrepancies elsewhere; earlier work had found only 7% agreement between widely used guidelines.

Surgery

Laparoscopy is preferred because of less pain, shorter hospital stay, quicker recovery and better cosmetic results. For ovarian endometriomas the guidelines follow a Cochrane review in which laparoscopic cystectomy of cysts larger than 3 cm was superior to drainage and ablation; according to ASRM, simple drainage has a recurrence rate of 80% to 100%. Surgery on endometriomas can reduce ovarian reserve, so measuring AMH before ovarian surgery should be considered. All guidelines except NICE and ASRM recommend excision of deep infiltrating nodules for pain, performed by experts because of substantial complication rates. Hysterectomy with excision of lesions is the last option for women who have completed their family planning; patients should be told there is about a 15% chance of persistent pain and a 3% to 5% risk of worsening or new symptoms. Laparoscopic uterine nerve ablation has no benefit.

Medical treatment

Dienogest, most commonly 2 mg per day, showed efficacy comparable to GnRH analogues with better tolerability in two trials. Medroxyprogesterone acetate, the levonorgestrel intrauterine system and combined oral contraceptives are also used; NSAIDs are a symptomatic first-line option but not for long-term use. GnRH agonists are reserved for persistent symptoms after first-line therapy, with limits on duration (no more than one year with add-back therapy according to CNGOF, 6 months according to SOGC). GnRH antagonists, aromatase inhibitors, SERMs and SPRMs are mentioned by some guidelines, but the evidence is insufficient; ACOG is the only guideline still proposing danazol as a possible first-line therapy.

Infertility

Surgical excision of endometriosis and endometriomas has the strongest evidence and is the standard approach, with ablation of ovarian endometriosis as second line. Medical therapies are in principle not recommended, except GnRH agonists for downregulation before IVF or surgery: WES, CNGOF and SOGC propose 3 to 6 months of downregulation before IVF, while ACOG and the German guideline consider the data inconclusive.

Frequently asked questions

What is the first-line medical treatment for endometriosis pain?

All eight guidelines recommend progestins as first-line medical treatment, and most propose combined oral contraceptives as a first empirical treatment.

Does surgery help women with endometriosis and infertility?

Excision of endometriosis and endometriomas has the strongest evidence for infertility, although the guidelines do not fully agree and the effect on ovarian reserve must be considered.

Is hysterectomy a cure for endometriosis?

It is a last resort; afterwards there is about a 15% chance of persistent pain and a 3% to 5% risk of worsening or new symptoms.

Source

Kalaitzopoulos DR, Samartzis N, Kolovos GN, et al. Treatment of endometriosis: a review with comparison of 8 guidelines. BMC Women's Health. 2021;21:397. DOI: 10.1186/s12905-021-01545-5. Open access under a Creative Commons Attribution 4.0 International licence (CC BY 4.0). This page is a summary prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.