Principles of Treatment Treatment of endometriosis must be individualized, taking into consideration the clinical problem in its entirety, including the impact of the disease and the effect of its treatment on quality of life. Evidence-based recommendations that are continuously updated can be found in the ESHRE guidelines for the clinical management of endometriosis (1).
In most women with endometriosis, preservation of reproductive function is desirable (1). Many women with endometriosis have pain and subfertility at the same time or may desire children after sufficient pain relief, which complicates the choice of treatment. Endometriosis surgery should be considered as reproductive surgery, recently defined by the World Health Organization (WHO) as “all surgical procedures carried out to diagnose, conserve, correct and/or improve reproductive function” (284). The least invasive and least expensive approach that is effective with the least long-term risks should be chosen (1). Symptomatic endometriosis patients can be treated with analgesics, hormones, surgery, assisted reproduction, or a combination of these modalities (1). Regardless of the clinical profile (subfertility, pain, asymptomatic findings), treatment of endometriosis may be justified because endometriosis appears to progress in 30% to 60% of patients within a year of diagnosis and it is not possible to predict in which patients it will progress (267). Elimination of the endometriotic implants by surgical or medical treatment often provides only temporary relief. In addition to eliminating the endometriotic lesions, the goal should be to treat the sequelae (pain and subfertility) often associated with this disease and to prevent recurrence of endometriosis (1). Endometriosis is a chronic disease and the recurrence rate is high after both hormonal and surgical treatment (1).
It is important to involve the patient in all decisions, to be ﬂexible in considering diagnostic and therapeutic approaches, and to maintain a good relationship. It may be appropriate to seek advice from more experienced colleagues or to refer the patient to a center with the necessary expertise to offer treatments in a multidisciplinary context, including advanced laparoscopic surgery and laparotomy (1,285). Because the management of severe or deeply infiltrating endometriosis is complex, referral is strongly recommended when disease of such severity is suspected or diagnosed (1).
Treatment of Endometriosis-Associated Pain
Pain may persist despite seemingly adequate medical or surgical treatment of the disease. A multidisciplinary approach involving a pain clinic and counseling should be considered early in the treatment plan. The least invasive and least expensive approach that is effective should be used (1).
Surgical Treatment Depending on the severity of disease, diagnosis and removal of endometriosis should be performed simultaneously at the time of surgery, provided preoperative consent was obtained (1,286–289). The goal of surgery is to excise all visible endometriotic lesions and associated adhesions—peritoneal lesions, ovarian cysts, deep rectovaginal endometriosis—and to restore normal anatomy (1). In most women, laparoscopy can be used, and this technique decreases cost, morbidity, and the possibility of recurrence of adhesions postoperatively (1). Laparotomy should be reserved for patients with advanced-stage disease who cannot undergo a laparoscopic procedure and for those in whom fertility conservation is not necessary (1).