In patients with severe endometriosis, it is recommended that surgical treatment be preceded by a 3-month course of medical treatment to reduce vascularization and nodular size (200). A randomized controlled study comparing presurgical medical therapy (3 months of GnRH agonists) with surgery alone in women with moderate to severe endometriosis showed a significant improvement in AFS scores in the medical therapy group (WMD −9.60; 95% CI, −11.42 to −7.78), without significant difference in ease of surgery between the two groups and without documentation of improved outcomes for the patients (323). Hormonal therapy prior to surgery improves r-AFS scores, but there is insufficient evidence of any effect on outcome measures such as pain relief (1,324).
Radical procedures such as oophorectomy or total hysterectomy are indicated only in severe situations and can be performed laparoscopically or by laparotomy. Women aged 30 years or younger at the time of hysterectomy for endometriosis-associated pain are more likely than older women to have residual symptoms, to report a sense of loss, and to report more disruption from pain in different aspects of their lives (325). If a hysterectomy is performed, all visible endometriotic tissue should be removed. Although associated with improved pain relief and a reduced chance of future surgery, a bilateral salpingo-oophorectomy in young women should be considered in only the most severe or recurrent cases (326,327). Resection is an effective treatment for rectovaginal endometriosis, in combination with hysterectomy (328).
When postoperative hormone therapy with estrogen is used after bilateral oophorectomy, there is a negligible risk for renewed growth of residual endometriosis (329). To reduce this risk, hormone therapy should be withheld until 3 months after surgery. The addition of progestins to this regimen protects the endometrium. The decision to start hormone therapy with a combination of estrogen and progestin should be balanced against the increased risk of breast cancer and heart disease associated with hormone therapy. Some cases of adenocarcinoma were reported, presumably arising from endometriosis lesions remaining in women treated with unopposed estrogen (330).