Treatment Guideline Chart

Endometriosis is an estrogen-dependent growth of extrauterine endometrial-like tissue that induces a chronic inflammatory response.

Main clinical features include chronic pelvic pain, dyspareunia and infertility.

Patients with endometriosis may also be completely asymptomatic.

Goals of treatment are decreasing pain, enhancing fertility, and preventing progression or recurrence. 


Surgical Intervention

  • Recommended in some circumstances to confirm the diagnosis and provide treatment to achieve pain relief or improve fertility ie “see and treat”
  • Surgery should only be done in women with endometriosis-related pain after medical treatment has failed
  • May improve fertility
    • Patient benefits from the mechanical clearance of adhesions and obstructive lesions  
    • Please see Infertility disease management chart for further information
  • Indications:
    • Symptoms are severe, incapacitating or acute, eg acute adnexal torsion or rupture of ovarian cyst
    • Symptoms have failed to resolve or have worsened under medical management
    • With advanced disease or invasive disease that affected the bowel, ureters, bladder or pelvic nerves
    • Anatomic distortion of the pelvic organs, endometriotic cysts or obstruction of the bowel or urinary tract
    • Patient declines or has contraindication to medical treatment
    • Endometriosis-related infertility, pain or pelvic mass
    • Treatment for postmenopausal endometriosis 
  • May be performed by laparoscopy or laparotomy
    • Laparoscopy is preferred over laparotomy for treatment of endometriosis-related infertility 
  • After surgery, the median time for pain recurrence is 20 months
  • May be classified as “conservative” or “definitive”

Conservative Surgery

  • Preserves the uterus and as much ovarian tissue as possible
  • Performed in women of reproductive age, those who wish to get pregnant, or those who wish to avoid menopausal induction at an early age  
  • Includes removal of macroscopic endometrial tissue, lysis of adhesions, and repair of normal anatomy
    • High recurrence rate (80-100%) is noted after 6 months of drainage of endometriomas
    • Excision of endometriomas provides better pain relief, decreased recurrence rate, a histopathological diagnosis, and improves chances of pregnancy 
      • Women with >3-cm ovarian endometriomas and with pelvic pain should be advised to undergo excision of endometrioma
    • Surgical ablation or resection of endometriosis plus laparoscopic adhesiolysis should be offered to patients with minimal or mild endometriosis who will undergo laparoscopy to improve chances of pregnancy
    •  Operative laparoscopy in patients with severe endometriosis increases spontaneous pregnancy rates

Laser Uterosacral Nerve Ablation (LUNA) 

  • Reduces pain in minimal-moderate endometriosis
  • Disrupts the efferent nerve to reduce uterine pain
  • Not performed as an additional procedure to conservative surgery for pain reduction as RCTs showed no additional benefit

Presacral Neurectomy 

  • Though rarely indicated, it may be helpful in decreasing midline pain (eg dysmenorrhea, dyspareunia) but not in other pelvic areas
  • May be considered adjunct to surgical management of endometriosis-related pelvic pain

Tubal Flushing 

  • Studies have shown that flushing of fallopian tubes using oil-soluble media may increase chances of pregnancy

Definitive Surgery


  • In women with ovarian endometrioma, cystectomy rather than drainage and coagulation or CO2 laser vaporization should be performed


  • Hysterectomy with or without removal of the fallopian tubes and ovaries
  • May be an option for patients with intractable pain despite conservative treatment, severe disease, and  if childbearing is no longer desired 
  • In young women who underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAHBSO), hormonal replacement therapy (HRT) is recommended
    • May give combined hormone therapy (estrogen and progestin) or Tibolone 
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