New Guideline: Management of Women With Endometriosis

Peter Kovacs, MD, PhD


March 21, 2014


Endometriosis is a rather common, benign gynecologic disease. It is defined as the presence of endometrial tissue outside the uterine cavity. The diagnosis is established by histologic confirmation of both endometrial glands and stroma in tissue specimens obtained at the time of surgery.

Asymptomatic endometriosis does not require surgical treatment, because the natural course of the disease is not known. Patients with recurrent symptoms that are not responsive to medical treatment and significantly affect everyday quality of life may need to be managed with definitive surgery: removal of the uterus and ovaries. For those with less severe symptoms, a wide variety of therapies can be offered.

Medical therapy may involve the use of nonsteroidal anti-inflammatory drugs when the main problem is the cyclic occurrence of painful symptoms. Hormonal therapy that suppresses endometriosis and induces the regression of endometrial tissue has been shown to improve pain, dysmenorrhea, and dyspareunia. OCPs, progestins, androgens, and GnRH agonists can all be considered for this purpose. Deep infiltrating endometriosis often requires surgical management. The procedure should be done by experienced surgeons, as the risk for bladder and bowel injury is relatively high and it may require the resection of the affected bowel segment.

Endometriosis can be detected in up to one third of infertile women.[3,4] Its impact depends on the stage of the disease. Even early-stage endometriosis may lower implantation rates. Surgical treatment of early-stage disease has been shown to improve pregnancy rates.[5] Advanced-stage endometriosis may distort the anatomy and could result in infertility. Surgical correction can be considered, but most of these patients will eventually require IVF. Suppression of endometriosis with a GnRH agonist or extended OCP use improves IVF outcome.

The management of ovarian cysts may pose a clinical dilemma. One the one hand, cysts may lower the response to stimulation, could interfere with successful oocyte collecting during IVF, and may be associated with pain. They may also increase the risk for adnexal torsion during pregnancy when left untreated. On the other hand, even the most careful surgery could negatively affect ovarian reserve when healthy tissue is removed as well. A patient with already compromised ovarian function is likely not to benefit from the surgery. For those without associated symptoms, the removal of endometriomas is not required. Patients with symptoms associated with endometriosis, however, most likely would benefit from surgery before fertility treatment.[6]

Endometriosis is associated with a wide variety of symptoms, and treatment is needed in symptomatic patients. Treatment may involve surgery, medical therapy, or a combination of the two. The treatment has to be individualized to address the patient’s symptoms and her desire for fertility. Treatment should also be determined by assessing the risk/benefit ratios of the various hormonal surgical options.



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