An update for endometriosis management: a position statement

Endometriosis is a complex disease and still many areas of uncertainty exist on the clinical management, from the diagnosis to the treatment. The modern diagnostic workup should include the family history (including genetic and epigenetic factors), the clinical presentation, an accurate gynecological examination and an imaging evaluation (transvaginal ultrasound and/or magnetic resonance) performed by expert practitioners. Laparoscopy must no longer be performed with the sole purpose of diagnosing endometriosis. Furthermore, a diagnosis of endometriosis should be already suspected among adolescents and young women with severe dysmenorrhea, interfering with daily activities and not responding to analgesic drugs. For patients without immediate desire of pregnancy, hormonal drugs are first line choices for treating endometriosis-related pain, aiming to reduce menstruation frequency and even abolishing any bleeding. Progestins or continuous combined oral contraceptives are used for long term treatment and should be prescribed as first-line option. In case of failure or intolerance, GnRH analogs or more recently oral GnRH antagonists may be proposed (with or without an add-back therapy). Surgery remains an important treatment option, but it should be performed at the right time, as a single operation, preferentially in referral centers by dedicated multidisciplinary teams, in order to avoid recurrences and/or repetitive surgery. Assisted reproductive technology (ART) is an option for treating endometriosis-related infertility either as first line approach, or after surgical approach. Fertility preservation can be discussed at the moment of diagnosis of endometriosis or before performing surgery when indicated.