Is there a definitive guideline for the surgical management of endometriosis?

Which guideline addresses patients' concerns over the surgical management of their endometriosis?

Key Points

Highlights:

• Current guidelines for the medical and surgical management of endometriosis continues to fall behind the ongoing development of drugs and techniques currently being researched in the field.

What’s done here? 

• This article reviews the guidelines from several societies on the surgical management of endometriosis.

Key Results:

The following are summary statements from the guidelines included in this article’s comparative analysis:

• Laparoscopy should be considered in patients with suspected superficial endometriosis and pain symptoms who do not respond to or have contraindications to medical therapy.
• In women without a previous diagnosis of endometriosis, ovarian endometriomas should be removed to obtain histologic confirmation that the cyst is benign.
• Removal of ovarian endometriomas should be performed by resection or ablation rather than drainage to lower the risk of recurrence.
• Currently, there are no society guidelines that indicate the preoperative workup of patients suspected to have deeply-involving endometriosis. However, several studies have shown that resection of deeply involving endometriosis improves pain and quality of life.
• Surgical management of endometriosis should take into account the patient’s fertility desires, clinical history, type of endometriosis, and specific symptoms.
• To date, a clearer recommendation for the clinical workup of endometriosis needs to be applied to a wide-scale standard of care for patients with endometriosis.

Limitations:

• This is an opinionated article.

Lay Summary

Endometriosis is a chronic inflammatory disease that is defined by the presence of ectopic endometrial tissue outside of the uterus. Unfortunately, endometriosis continues to be a leading cause of chronic pelvic pain in women of reproductive age.

This article titled, “Surgical treatment of different types of endometriosis…” by Kho et al. from the Women’s Health Institute in Cleveland clinic and institutions in Sao Paulo, Brazil aim to elucidate and compare the current treatment options and guidelines for patients with different types of endometriosis.

Several societies publish guidelines for the surgical treatment of endometriosis. Data from groups such as the ESHRE, ACOG, ASRM, SOGC, and EBRASGO were collected and subsequently compared according to the specific type of endometriosis in question.

For superficial endometriosis (or peritoneal) most of the guidelines agreed that when diagnosed during laparoscopy, surgical resection is preferred because resection allows for histologic confirmation and improves chronic pain symptoms for the majority of patients. According to these societies, patients who do not respond to or cannot initiate medical therapy should be considered for laparoscopy.

Approximately 30% of asymptomatic women with infertility ultimately have endometriosis. For infertility, laparoscopy has been shown to increase the rate of successful pregnancies within one year by 8.6%. Thus, several societies have recommended that laparoscopy is considered for women with infertility if they are suspected to have minimal or mild endometriosis.

The surgical treatment of ovarian endometriomas is complicated by the fact that treatment can decrease ovarian reserve and cause long-term complications. Thus, expert clinical judgment is recommended for these cases that take into account patient preferences for future pregnancy and other patient factors. The ESHRE in 2014 published guidelines that recommended ovarian cystectomy (rather than drainage and coagulation) and removal of the capsule (as opposed to laser vaporization) to optimize recurrence rates and spontaneous pregnancy rates.

Definitive guidelines on the management of endometriosis continue to lag behind the current developments currently being made. An emphasis on guidelines for nonsurgical imaging methods for screening, surgical optimization for fertility outcomes, and clinical indications still need to become standard of care.

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/29545114