Is there a new gold standard for endometriosis treatment in 2025?

Gold Standard for Endometriosis Treatment in 2025

Laparoscopic surgery remains the gold standard for both diagnosis and treatment of endometriosis in 2025, as it is the only universally accepted method of definitive diagnosis and an effective treatment option. 1

Diagnostic and Classification Approach

Laparoscopic diagnosis continues to be essential because:

• It allows direct visualization and histological confirmation of endometriotic lesions
• It enables proper classification using the recommended toolbox approach:
  • r-ASRM classification for all women undergoing surgery
  • Enzian classification for those with deep infiltrating endometriosis
  • Endometriosis Fertility Index (EFI) for women concerned about future fertility 1

Treatment Algorithm Based on Patient Priorities

For Pain Management:

1. First-line medical therapy:

   • Hormonal treatments including norethindrone acetate (FDA-approved specifically for endometriosis) 2
   • Goal: Induce a hypoestrogenic state to cause atrophy of endometriotic tissue

2. Surgical approach:

   • Laparoscopic excision or ablation of visible lesions
   • Particularly effective for deep infiltrating endometriosis affecting quality of life

3. Post-surgical management:

   • Consider hormonal suppression to prevent recurrence
   • Tailored based on disease stage and location

For Fertility Preservation/Enhancement:

1. Surgical approach is preferred:

   • Laparoscopic removal of endometriotic lesions has been demonstrated to increase fecundity
   • Avoid hormonal suppression as it prevents conception 3

2. Post-surgical management:

   • Consider assisted reproductive technologies based on EFI score
   • Avoid long-term hormonal suppression that delays fertility attempts

Important Considerations and Pitfalls

• Disease staging does not correlate with pain severity: This creates challenges in treatment planning and expectations management 4

• Recurrence risk: Even after optimal surgical treatment, endometriosis has a significant recurrence rate, necessitating ongoing management strategies

• Fertility impact: Medical treatments that suppress ovulation (hormonal therapies) should be avoided in women actively seeking pregnancy 3

• Quality of life considerations: Treatment decisions should prioritize impact on daily functioning and overall wellbeing, not just symptom or lesion reduction

Emerging Approaches

While not yet established as the gold standard, several promising approaches are in development:

• Targeted immunomodulators addressing endometriosis-associated inflammation
• Selective progesterone receptor modulators
• Aromatase inhibitors
• Antiangiogenic agents 5

These emerging therapies may eventually allow for more personalized treatment approaches that maintain normal menstrual cycles and fertility while controlling symptoms 6.