An Overview on Treatment of endometriosis

Comparing eight commonly used national and international therapeutic guidelines for endometriosis.

Key Points

Importance:

• As the current guidelines have some discrepancies, an overview of therapeutical approaches on widely used guidelines for endometriosis is helpful.

Highlights:

• All eight guidelines agree on the recommendation of the combined oral contraceptive and progestogen treatment for pain in endometriosis. 
• There is no clear consensus about surgical treatment for infertility.

What's done here:

• Six national and two international guidelines concerning the diagnosis and treatment of endometriosis were evaluated.
• Tho make an overview of therapeutical approaches, 2independent reviewers evaluated all the available guidelines and extracted the recommendations.

Key Results:

• For chronic pain of endometriosis and infertility, all the guidelines recommend laparoscopic surgery in preference to laparotomy. 
• None state robotic surgery as an option for endometriosis surgery.
• Almost all agree that patients with suspected mild endometriosis and infertility should be considered candidates for surgical treatment. 
• Five (CNGOF, ESHRE, S2k, ASRM, and SOGC) recommend the surgical treatment of superficial endometriosis for patients with endometriosis-associated pain.
• All guidelines concur on laparoscopic cystectomy of endometriomas >3 cm is superior to drainage and electro-ablation.
• There are differences in the excision of deep endometriosis and the use of preoperative imaging techniques.
• When a patient has fulfilled family planning and fails to respond to conservative treatment, hysterectomy and the excision of endometriotic lesions are advised by all the guidelines.
• No agreement on adhesiolysis, uterine nerve ablation.
• Progestins are recommended as the first-line medical treatment by all the evaluated guidelines.  

Lay Summary

There are different guidelines by different gynecological societies for the diagnosis and treatment of endometriosis, which is an extremely complex illness. 

Kalaitzopoulos and Samartzis et al. from Switzerland worked on and compared six national and two international widely used guidelines to evaluate and compare the similarities and the differences between the guidelines. The results of the comparison and overview of six national (National German Guideline-S2k, Society of Obstetricians and Gynecologists of Canada, American College of Obstetricians and Gynecologists (ACOG), American Society of Reproductive Medicine (ASRM), and National Institute for Health and Care (NICE) and two international guidelines [by World Endometriosis Society (WES) and the European Society of Human Reproduction and Embryology (ESHRE)] have recently published in BMC Women's Health.

Surgical guidelines were reviewed as peritoneal, ovarian, and deeply infiltrated endometriosis whereas the referred operations were hysterectomy, adhesiolysis, laparoscopic uterine nerve ablation (LUNA), and presacral neurectomy (PSN). Medical treatment options were reviewed under the topics as progestins, combined oral contraceptives, non-steroidal anti-inflammatory drugs (NSAID), gonadotropin-releasing hormones  (GnRH)agonists, and antagonists, aromatase inhibitors, danazol, gestrinone, selective estrogen receptor modulators (SERM), selective progestin receptor modulators (SPRM), and non-hormone therapies.

All the guidelines recommended laparoscopic surgery compared to laparotomy for chronic pain of endometriosis and infertility, and none state robotic surgery as an option for endometriosis surgery. Almost all the guidelines agreed that patients with suspected mild endometriosis and infertility should be considered candidates for surgical treatment.  All the guidelines concurred on laparoscopic cystectomy for endometriomas bigger than 3 cm. Again, all the guidelines advised hysterectomy and the excision of endometriotic lesions when the patient has fulfilled family planning and fails to respond to conservative treatment. Similarly, Progestins are recommended as the first-line medical treatment by all the evaluated guidelines.  

There are differences in the excision of deep endometriosis adhesiolysis, uterine nerve ablation, and the use of preoperative imaging techniques.

Complementary therapies, dietary products, acupuncture, and electrotherapy are not accepted as therapeutic options because of the lack of evidence. 

Research Source: https://pubmed.ncbi.nlm.nih.gov/34844587