What are the 2026 American College of Obstetricians and Gynecologists (ACOG) guidelines for evaluating and managing endometriosis in a woman of reproductive age, including recommended diagnostic work‑up, first‑line medical therapy, second‑line options, fertility‑preserving surgery, and indications for definitive surgery?

ACOG 2026 Guidelines on Endometriosis

Diagnosis

ACOG recommends that endometriosis can be diagnosed clinically based on characteristic symptoms without requiring surgical confirmation, though histologic examination remains the gold standard for definitive diagnosis. 1

Clinical Presentation

• Three characteristic pain patterns identify endometriosis: (1) secondary dysmenorrhea beginning before menstrual onset, (2) deep dyspareunia that worsens during menses, and (3) sacral backache coinciding with menstruation 1
• Greater depth of endometriotic infiltration correlates with increased pain severity, whereas the specific type of lesion observed during laparoscopy shows little relationship to pain intensity 1
• Chronic non-menstrual pelvic pain lasting at least six months outside the menstrual cycle suggests endometriosis 2

Diagnostic Work-Up

• Experienced surgeons may rely on visual inspection alone during laparoscopy when lesions have classical appearance 1
• Peritoneal biopsy should be performed when peritoneal lesions are uncertain to establish definitive diagnosis 1
• Serum CA-125 has limited diagnostic utility, particularly in mild or minimal endometriosis 1
• Transvaginal ultrasound and/or pelvic MRI should be obtained for preoperative mapping of disease extent, identifying deep infiltrating lesions 3
• Normal physical examination and imaging do not exclude the diagnosis 4

First-Line Medical Management

ACOG confirms that combined oral contraceptives and progestins are first-line hormonal therapies, providing effective pain relief compared to placebo and equivalent efficacy to more costly regimens. 1, 3

Hormonal Therapy Options

• NSAIDs are recommended as first-line approach for immediate pain relief 1
• Combined oral contraceptives (continuous or cyclic) provide effective pain relief with superior safety profiles 3
• Progestins (oral norethindrone 0.35 mg daily or depot medroxyprogesterone acetate) demonstrate similar efficacy to oral contraceptives 1, 2
• Hormonal medications should be offered to symptomatic premenopausal women who do not currently desire pregnancy 4

Treatment Limitations

• No medical therapy eradicates endometriotic lesions completely 1
• 11% to 19% of individuals have no pain reduction with hormonal medications 4
• 25% to 34% experience recurrent pelvic pain within 12 months of discontinuing hormonal treatment 4
• Medical treatment does not improve future fertility outcomes 1

Second-Line Medical Management

When first-line therapies fail, ACOG recommends GnRH agonists for at least 3 months, which provide significant pain relief even without surgical confirmation of endometriosis. 1, 3

GnRH Agonist Protocol

• Mandatory add-back therapy (norethindrone acetate 5 mg daily with or without low-dose estrogen) must be implemented when using GnRH agonists long-term to prevent bone mineral loss without reducing pain relief efficacy 1, 3
• Leuprolide 3.75 mg intramuscularly monthly or 11.25 mg every 3 months are standard dosing regimens 1
• GnRH agonists and danazol (≥6 months) provide comparable pain relief 1

Alternative Second-Line Options

• Dienogest 2 mg is effective but contraindicated in low-grade serous epithelial ovarian cancer, granulosa-cell tumors, certain sarcomas, and advanced endometrioid uterine adenocarcinoma 3
• Acne occurs in fewer than 10% of women treated with dienogest 3

Surgical Management

ACOG indicates that surgical intervention should be considered when medical treatment is ineffective, contraindicated, or for severe endometriosis, with surgery providing significant pain reduction during the first six months post-procedure. 1, 3

Fertility-Preserving Surgery

• Surgical excision by a specialist is the definitive treatment for endometriosis 3
• Laparoscopic approach is preferred unless suspected involvement of pelvic or abdominal organs cannot be safely managed laparoscopically 3
• Systematic exploration, inspection, and palpation of entire abdomen and pelvis should be performed 3
• Bowel resection should be performed when necessary to achieve complete disease removal or prevent obstruction 3
• Bladder endometriosis requires partial cystectomy with complete excision of visible disease 3

Surgical Outcomes and Limitations

• Up to 44% of women experience symptom recurrence within one year after surgery 1, 2
• Preoperative imaging reduces morbidity and mortality by decreasing incomplete surgeries and need for repeat procedures 3
• Approximately 25% of patients who undergo hysterectomy for endometriosis experience recurrent pelvic pain and 10% undergo additional surgery 4

Definitive Surgery

For women who have completed childbearing and failed conservative management, hysterectomy with bilateral salpingo-oophorectomy remains the definitive approach. 3

Indications for Definitive Surgery

• Severe endometriosis unresponsive to medical and conservative surgical management 3
• Completed childbearing with persistent debilitating symptoms 3

Important Considerations

• Ovarian preservation can be considered in selected cases depending on patient's age and genetic risk factors, though bilateral oophorectomy provides more complete hormonal suppression 3
• If hysterectomy is performed without oophorectomy, ongoing medical suppression may still be required as residual ovarian function can stimulate remaining endometriotic tissue 3
• Hormone replacement therapy with estrogen is not contraindicated following hysterectomy and bilateral salpingo-oophorectomy for endometriosis 3

Pain Crisis Management

For acute endometriosis pain crisis, limit ketorolac to maximum 5 days due to gastrointestinal and renal risks. 1

Acute Pain Management

• Tramadol 50-100 mg every 6 hours shows superior efficacy to naproxen for endometriosis pain 1
• Transition from parenteral to oral NSAIDs (naproxen 550 mg twice daily or ibuprofen 600-800 mg three times daily) 1
• Start GnRH agonist therapy immediately with simultaneous add-back therapy 1

Adjunctive Non-Pharmacologic Measures

• Heat application to abdomen or back may reduce cramping pain 1
• Acupressure on Large Intestine-4 (LI4) or Spleen-6 (SP6) points may help reduce cramping pain 1
• Aromatherapy with lavender may increase satisfaction and reduce pain or anxiety 1

Critical Pitfalls to Avoid

• Diagnosis is often delayed, averaging 5 to 12 years after onset of symptoms, with most women consulting 3 or more clinicians prior to diagnosis 4
• Pain severity correlates poorly with laparoscopic appearance but correlates with lesion depth 1
• Hormonal suppression should not be used in women actively seeking pregnancy 3
• Endometriosis can rarely persist or recur in postmenopausal individuals not receiving hormone therapy 2

Cardiovascular Risk Considerations

Individuals with endometriosis have a 16-34% increased risk of stroke and are associated with hypercholesterolemia, hypertension, and increased cardiovascular disease risk. 2

• Screening for history of endometriosis is reasonable to inform stroke risk assessment 2
• Vascular risk factor evaluation and modification are reasonable to reduce stroke risk 2