When more is not better: 10 ‘don’ts’ in endometriosis management. An ETIC* position statement

Abstract

A network of endometriosis experts from 16 Italian academic departments and teaching hospitals distributed all over the country made a critical appraisal of the available evidence and definition of 10 suggestions regarding measures to be de-implemented. Strong suggestions were made only when high-quality evidence was available. The aim was to select 10 low-value medical interventions, characterized by an unfavorable balance between potential benefits, potential harms, and costs, which should be discouraged in women with endometriosis. The following suggestions were agreed by all experts: do not suggest laparoscopy to detect and treat superficial peritoneal endometriosis in infertile women without pelvic pain symptoms; do not recommend controlled ovarian stimulation and IUI in infertile women with endometriosis at any stage; do not remove small ovarian endometriomas (diameter <4 cm) with the sole objective of improving the likelihood of conception in infertile patients scheduled for IVF; do not remove uncomplicated deep endometriotic lesions in asymptomatic women, and also in symptomatic women not seeking conception when medical treatment is effective and well tolerated; do not systematically request second-level diagnostic investigations in women with known or suspected non-subocclusive colorectal endometriosis or with symptoms responding to medical treatment; do not recommend repeated follow-up serum CA-125 (or other currently available biomarkers) measurements in women successfully using medical treatments for uncomplicated endometriosis in the absence of suspicious ovarian cysts; do not leave women undergoing surgery for ovarian endometriomas and not seeking immediate conception without post-operative long-term treatment with estrogen–progestins or progestins; do not perform laparoscopy in adolescent women (<20 years) with moderate–severe dysmenorrhea and clinically suspected early endometriosis without prior attempting to relieve symptoms with estrogen–progestins or progestins; do not prescribe drugs that cannot be used for prolonged periods of time because of safety or cost issues as first-line medical treatment, unless estrogen–progestins or progestins have been proven ineffective, not tolerated, or contraindicated; do not use robotic-assisted laparoscopic surgery for endometriosis outside research settings. Our proposal is to better address medical and surgical approaches to endometriosis de-implementing low-value interventions, with the aim to prevent unnecessary morbidity, limit psychological distress, and reduce the burden of treatment avoiding medical overuse and allowing a more equitable distribution of healthcare resources.

Comorbidities and Quality of Life in Women Undergoing First Surgery for Endometriosis: Differences Between Chinese and Italian Population

“…In addition, the study involved only referral hospitals for endometriosis with expertise in both surgical and medical treatment of the disease. Their protocols for endometriosis management were similar, following international guidelines [ 14 , 22 , 23 ]: depending on age, pregnancy desire, pain symptoms, endometriosis phenotype, and each woman’s wishes, an individualized management was planned. Younger age at surgery may denote, on one hand, a more aggressive presentation of the disease, whereas on the other it may contribute to more severe symptoms and worse QoL in Italian women with endometriosis [ 2 ].…”

Hormonal treatments for endometriosis: The endocrine background

“…COCs are currently used off label for the treatment of endometriosis, however they are commonly used as empirical therapy for women with suspect of endometriosis, without a confirmed surgical diagnosis of the disease [242]. ESHRE guidelines classifies as Grade B the COCs prescription to reduce dyspareunia, dysmenorrhea and non-menstrual pain.…”

Oocyte Vitrification for Fertility Preservation in Women with Benign Gynecologic Disease: French Clinical Practice Guidelines Developed by a Modified Delphi Consensus Process

“…FP is a major concern for women with endometriosis, given the impact on their fertility of the disease and of the surgery required to treat it. The risk of diminished ovarian reserve after endometrioma surgery is well documented, and the indications for ovarian cystectomy have decreased [14]. Laparoscopic surgery might increase the pregnancy rate, but for now, no RCT has studied the live birth rate and the effect of laparoscopy on fertility remains uncertain [15].…”