What is the diagnosis and treatment for endometriosis?

From the Guidelines

Endometriosis treatment should prioritize a multimodal approach, including hormonal therapies, pain management, and lifestyle modifications, with the goal of improving quality of life, reducing morbidity, and minimizing mortality risk.

Treatment Options

• Over-the-counter pain relievers like ibuprofen (400-800mg every 6-8 hours) or naproxen (500mg twice daily) are often the first line of treatment for managing pain associated with endometriosis 1.
• Hormonal therapies, such as combined oral contraceptives taken continuously, or progestins like norethindrone acetate (5-15mg daily) or medroxyprogesterone acetate, can help reduce symptoms by suppressing estrogen production, which fuels endometriotic tissue growth 1.
• For more severe cases, GnRH agonists such as leuprolide (3.75mg monthly injection) may be prescribed, usually with add-back hormone therapy to prevent bone loss, as this approach has been shown to be effective in reducing pain and improving quality of life 1.

Surgical Interventions

• Surgical options, including laparoscopic excision or ablation of endometriotic lesions, can be effective in reducing pain and improving fertility outcomes, especially when combined with medical therapy 1.
• Hysterectomy may be considered for women who have completed childbearing and have severe symptoms, but this should be a last resort due to its invasive nature and potential long-term consequences 1.

Lifestyle Modifications

• Regular exercise, heat therapy, and dietary changes (reducing inflammatory foods) may help manage symptoms and improve overall well-being in women with endometriosis 1.

Classification and Diagnosis

• The revised American Society for Reproductive Medicine (r-ASRM) classification system is currently the most widely used system for classifying endometriosis, but its limitations in predicting symptoms and prognosis are recognized, and newer systems like the Enzian classification and the endometriosis fertility index (EFI) are being explored for their potential to improve diagnosis and treatment planning 1.

Key Considerations

• Individualized treatment plans are crucial, as endometriosis affects each person differently, and therapy should be aimed at pain management, fertility preservation, and preventing disease progression.
• A multidisciplinary approach, involving healthcare providers from various specialties, is essential for providing comprehensive care and improving outcomes for women with endometriosis. Ultimately, the most effective treatment strategy for endometriosis will depend on the individual patient's needs, symptoms, and medical history, and should be guided by the most recent and highest-quality evidence available.

From the Research

Definition and Symptoms of Endometriosis

• Endometriosis is a chronic benign disease that affects women of reproductive age 2, 3, 4, 5.
• The disease causes symptoms of pain and infertility, with the pain syndrome being quite incapacitating 5.
• The pain symptoms usually originate in the reproductive organs but can also involve the urinary or intestinal tracts if endometriosis implantation has occurred there 5.

Diagnosis of Endometriosis

• The only definitive diagnostic technique is laparoscopy 5.
• Initial treatment is surgical or medical, with medical therapy often used as a first-line therapy and can also be used in conjunction with those patients who undergo surgical therapy for pain 5.

Medical Management of Endometriosis

• Medical therapy consists mostly of hormonal suppressive therapy in which the medication causes a downregulation of the hypothalamus-pituitary-ovarian pathway 5.
• Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used in the treatment of chronic inflammatory conditions, being efficacious in relieving primary dysmenorrhea 2, 3, 4, 6.
• Combined oral contraceptives (COCs) and progestins are effective first-line hormonal options, improving pain symptoms in the majority of patients, and are well tolerated and not expensive 3, 4.
• Gonadotropin-releasing hormone (GnRH) agonists are prescribed when first-line therapies are ineffective, not tolerated, or contraindicated, but have a less favorable tolerability profile and are not orally available 3, 4, 5.
• Gonadotropin-releasing hormone (GnRH) antagonists, including elagolix, relugolix, and linzagolix, allow oral administration, induce dose-dependent reduction of estradiol levels, and do not cause initial flare-up of endometriosis symptoms 6.

Surgical Management of Endometriosis

• Surgical techniques include laparoscopic uterosacral nerve ablation/resection and presacral neurectomy 2.
• Surgical management relies on various methods, including excision/ablation of the lesions, nerve ablation, neurectomy, hysterectomy, and oophorectomy 2.
• No studies have directly compared medical versus surgical management, and as such, no one treatment modality can be recommended as superior to the other 2.

Emerging Therapies for Endometriosis

• Aromatase inhibitors have shown promise but are still under scrutiny and should be reserved only for women with symptoms who are refractory to other treatments only in a research environment 2, 3, 4, 5.
• Immunomodulators are also being investigated as a potential treatment for endometriosis 5.
• New delivery systems are being investigated that may also improve the patient response 5.
• Elagolix, relugolix, and linzagolix are oral GnRH antagonists that have shown efficacy in treating endometriosis-associated pain and are currently in late-stage clinical development or have been approved for use 6.