Clearing Up Confusion in Endometriosis Care (Part 1)

Endometriosis Management: Navigating ACOG Guidelines

Management strategies for endometriosis aim primarily to alleviate pain and, when needed, support fertility, yet confusion and inconsistency in recommendations remain alarming. This article reviews and comments on key current management strategies supported by the American College of Obstetrics and Gynecologists (ACOG), referencing Bulletin #114 (2010, reaffirmed 2022) and Bulletin #760 concerning adolescents (2018, reaffirmed 2022). In the following posts, we will review other guidelines to provide a more in-depth look at these inconsistencies and what you may face as you navigate your journey with endometriosis.

Other internationally recognized bodies have also published guidelines to aid clinicians in diagnosing and treating endometriosis. Unfortunately, discrepancies between recommendations are significant, reflecting the complex nature of the disease and research limitations to date. Many patients turn to online resources and forums after seeing providers and not achieving results, only to find that information on sites dedicated to endometriosis often conflicts with what various guideline resources propose.

Surgery

Surgery is considered a cornerstone in managing pain and infertility associated with endometriosis. The timing of surgery and the type of procedure recommended vary among guidelines. ACOG guideline Bulletin #114 states that “definitive diagnosis of endometriosis only can be made by histology of lesions removed at surgery.”

Minimally invasive surgery is preferred over open surgery (laparotomy) because it is associated with less pain, shorter hospital stays, faster recovery, and better cosmetic results. Regardless of whether the approach is laparoscopic or robotically assisted, a high level of surgical skill and expertise is required. Although robotic platforms offer advanced technology, outcomes research does not clearly demonstrate superiority of one modality over another, and the surgeon’s skill likely matters more than the tools used. Robotic surgery may be particularly well suited for difficult cases with severely distorted anatomy due to advanced disease or scarring from repeat surgeries.

Excision of endometriosis is widely recommended for endometriosis-associated pain. However, the preferred technique—ablation versus excision—remains debated due to a lack of conclusive evidence. Existing studies comparing excision with ablation have notable limitations, potentially reflecting variability in surgeons’ skill and training. In other words, some studies may not have involved true excision specialists, resulting in incomplete removal and skewed outcomes. This variation in expertise is a common challenge in research on surgical procedures.

For ovarian endometriosis (endometriomas or chocolate cysts), minimally invasive excision is superior to drainage and ablation in reducing recurrence of dysmenorrhoea, dyspareunia, cyst recurrence, and the need for further surgical interventions.

When family planning is complete and conservative treatments have failed, hysterectomy with simultaneous excision of endometriotic lesions is considered a last resort. Except in cases with coexisting adenomyosis, hysterectomy is not necessarily required for pain relief. Each situation should be highly individualized.

Medical Management of Endometriosis

While surgery helps many patients, medical management plays a crucial role in symptom control and fertility preservation, focusing on pain management, hormonal suppression, and birth control.

Pain management is fundamental. Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for symptomatic treatment of dysmenorrhea and acyclic pelvic pain. In its discussion of dysmenorrhea and endometriosis in adolescents, ACOG asserts—without any workup—that the majority of adolescents have primary dysmenorrhea, defined as painful menstruation in the absence of pelvic pathology, and recommends first-line therapies such as NSAIDs and birth control. This raises concerns: without definitive assessment (surgery) for endometriosis and given that imaging is insufficient for diagnosis, how is pelvic pathology excluded? Furthermore, ACOG considers symptomatic response to birth control pills and NSAIDs as confirmation of primary dysmenorrhea, though some people with endometriosis also respond symptomatically to these treatments.

Hormonal suppression using progestins, combined oral contraceptives, micronized progesterone, or Gonadotropin-releasing hormone (GnRH) analogues is a common strategy. This approach assumes estrogen is responsible for endometriosis, but it reflects an incomplete understanding of disease genesis and progression. Hormones are clearly involved, yet increasing molecular evidence indicates they are not the sole driver of endometriosis growth.

Combined oral contraceptives are often used as a first-line therapy for endometriosis-associated pain. By suppressing ovulation, they may help slow the growth of endometriotic tissue; however, they have not been proven to induce regression or resolution.

GnRH analogues are recommended as second-line options for endometriosis-associated pain and work by suppressing estrogen production, thereby theoretically reducing the growth of endometriotic tissue. In this context, ACOG states that “there is no data that support the use of preoperative medical suppressive therapy,” yet in clinical practice, many individuals are offered these medications inconsistently with respect to the consideration or timing of surgery. Additionally, ACOG’s level B evidence (second level) recommendations state: “After an appropriate pretreatment evaluation (to exclude other causes of chronic pelvic pain) and failure of initial treatment with OCs (oral contraceptives) and NSAIDS, empiric therapy with a 3-month course of a GnRH agonist is appropriate.” It can be argued that this is problematic given the lack of conclusive data supporting the use of these medications prior to surgery, and there is a significant risk of short- and potentially long-term side effects and complications.

Complementary Therapies

Complementary options such as dietary interventions, acupuncture, and electrotherapy are gaining recognition as potential adjuncts. While there is supportive evidence for several approaches, more research is needed to establish efficacy and safety. As a result, guidelines do not routinely address these modalities, often leaving patients to rely on personal trial and error.

Conclusion

Managing endometriosis typically requires a multifaceted approach, combining surgical and medical treatments that must be tailored to each patient. In recent years, research and advocacy have improved. Finding a knowledgeable, specialized surgeon and care team is of utmost importance. The majority of OBGYNs do not focus on endometriosis, have not undergone further specialized training, and generally align with ACOG guidelines, often influenced by perceived medico-legal concerns related to standard of practice. Notably, other guidelines also differ in their opinions and recommendations regarding medical management and surgery.