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Diagnosis and Management of Endometriosis
ANNE L. MOUNSEY, M.D., University of Virginia School of Medicine, Charlottesville, Virginia
ALEX WILGUS, M.D., Lynchburg Family Medicine Residency Program, Lynchburg, Virginia
DAVID C. SLAWSON, M.D., University of Virginia School of Medicine, Charlottesville, Virginia
Signs and symptoms of endometriosis are nonspecific, and an acceptably accurate noninvasive diagnostic test has yet to
be reported. Serum markers do not provide adequate diagnostic accuracy. The preferred method for diagnosis of endo-
metriosis is surgical visual inspection of pelvic organs with histologic confirmation. Such diagnosis requires an expe-
rienced surgeon because the varied appearance of the disease allows
less-obvious lesions to be overlooked. Empiric use of nonsteroidal
anti-inflammatory drugs or acetaminophen is a reasonable symptom-
atic treatment, but the effectiveness of these agents has not been well-
studied. Oral contraceptive pills, medroxyprogesterone acetate, and
intrauterine levonorgestrel are relatively effective for pain relief. Dan-
azol and various gonadotropin-releasing hormone analogues also are
effective but may have significant side effects. There is limited evidence
that surgical ablation of endometriotic deposits may decrease pain
and increase fertility rates in women with endometriosis. Presacral
neurectomy is particularly beneficial in women with midline pelvic
pain. Hysterectomy and bilateral salpingo-oophorectomy definitively
treat pain from endometriosis at 10 years in 90 percent of patients.
(Am Fam Physician 2006;74:594-600, 601-2. Copyright 2006 Ameri-
can Academy of Family Physicians.)
 Patient information:
A handout on endome-triosis is provided on page 601.
The online version Endometriosis is characterized by the The most widely held theory involves the ret- presence of endometrial tissue out- rograde reflux of menstrual tissue from the side the endometrial cavity. These fallopian tubes during menstruation. Two ectopic deposits of endometrium other possibilities are the celomic metapla- may be found in the ovaries, peritoneum, sia and embryonic rests theories. Celomic uterosacral ligaments, and pouch of Douglas metaplasia hypothesizes that the mesothe- mental content at http:// (Figure 1). Rarely, extrapelvic deposits of lium covering the ovaries invaginates into endometrial tissue are found.
the ovaries, then undergoes metaplasia into Morbidity rates associated with endometri- endometrial tissue. The embryonic rests the- osis are considerable. Between 1990 and 1998, ory hypothesizes that Müllerian remnants endometriosis was the third most common in the rectovaginal region differentiate into gynecologic diagnosis listed in hospital dis- endometrial tissue. A woman's risk for endo- charge summaries of women 15 to 44 years of metriosis increases with increased exposure age.1 The prevalence of endometriosis in the to endometrial material; thus, shorter men-general population is estimated to be 10 per- strual cycles, longer bleeding, and early men- cent.2 A much higher prevalence of up to arche are risk factors (Table 1).2,6-10 Being 82 percent occurs in women with pelvic pain, overweight and smoking have been associ-and in women undergoing investigation for ated with a lower risk of endometriosis.11 infertility the prevalence is 21 percent.2-4 The prevalence in women undergoing steriliza- tion is 3.7 to 6 percent.3,5 clinical PrEsEntation
Endometriosis usually becomes apparent in
the reproductive years when the lesions are Several theories have been suggested to stimulated by ovarian hormones. Symptoms explain the pathogenesis of endometriosis. tend to be strongest premenstrually, subsiding Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright 2006 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.
The preferred method for diagnosing endometriosis is direct visualization of lesions with histologic Danazol (Danocrine) may be used for pain relief in patients with endometriosis.
OCPs, progesterone-only OCPs, and medroxyprogesterone acetate (Provera) should be used as first-line therapies for treating pain associated with endometriosis.
Because gonadotropin-releasing hormone analogues provide equivalent pain relief as OCPs and progestogens with more side effects, they should be used only as second- or third-line agents.
Surgical ablation of endometrial deposits with or without laparoscopic uterine nerve ablation can be performed for pain relief.
Laparoscopic surgery can be performed in women with subfertility and endometriosis.
Presacral neurectomy can be performed in women with midline abdominal pain from endometriosis.
Laparoscopic cystectomy is preferred over drainage for pain relief in women with endometriosis.
OCPs = oral contraceptive pil s. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 542 or http://www.aafp.org/afpsort.xml. after cessation of menses. Pelvic pain is the
most common presenting symptom; other
symptoms include back pain, dyspareunia,
loin pain, dyschezia (i.e., pain on defeca-
tion), and pain with micturition. A patient
survey of women in the United Kingdom and
United States who were referred to univer-
sity-based endometriosis centers found that
70 to 71 percent presented with pelvic pain,
71 to 76 percent with dysmenorrhea, 44 per-
cent with dyspareunia, and 15 to 20 percent
with infertility.12 In a British study of women Figure  1.  Laparoscopic view of deposits of
with pelvic pain, many patients who even- endometrial tissue (arrow) on the ovary.
tually were diagnosed with endometriosis had been diagnosed previously with irritable bowel syndrome.13 Endometriosis is associ- ated with infertility because of adhesions that distort the pelvic anatomy and cause impaired ovum release and pickup. However, 95% confidence tubal distortion is not the only cause of infer-tility, because patients with endometriosis Mother or sister has endometriosis/mother seem to have poor ovarian reserve with low and sister do not have endometriosis oocyte and embryo quality. A meta-analysis Menstrual flow six days or more/flow less of 22 studies evaluating in vitro fertilization outcomes found that patients with endome- Menstrual cycle less than 28 days/cycle of triosis had a pregnancy rate of nearly one half Consuming one or more alcoholic drinks that of patients without endometriosis, with per week/no alcohol consumption decreases in fertilization, implantation, and Never used OCPs/ever used OCPs oocyte production rates.14 Use of pads and tampons/use of either The preferred method for the diagno- OCPs = oral contraceptive pil s. sis of endometriosis is direct visualization Information from references 2 and 6 through 10. of ectopic endometrial lesions (usually via August 15, 2006 ◆ Volume 74, Number 4 www.aafp.org/afp American Family Physician  595
Secondary (e.g., adenomyosis, myomas, Neoplasms, benign or malignant infection, cervical stenosis) Nongynecologic causes Diminished lubrication or vaginal expansion because of insufficient arousal Pelvic inflammatory disease Gastrointestinal causes (e.g., constipation, Sexual or physical abuse irritable bowel syndrome) Musculoskeletal causes (e.g., pelvic relaxation, Cervical factors (e.g., mucus, sperm, antibodies, stenosis) Pelvic vascular congestion Luteal phase deficiency Urinary causes (e.g., urethral syndrome, interstitial cystitis) Male factor infertilityTubal disease or infection Information from reference 16. laparoscopy) accompanied by histologic con- symptoms in the diagnosis of endometriosis firmation of the presence of at least two of the in women who present with infertility.17 following features: hemosiderin-laden mac- Although no test provides strong evidence rophages or endometrial epithelium, glands, for the presence of endometriosis, the symp-or stroma.15 Diagnosis based solely on visual tom of uterosacral pain has the highest posi-inspection requires a surgeon with experi- tive likelihood ratio.
ence in identifying the many possible appear-
ances of endometrial lesions; nonetheless, Diagnostic tEsts
there is relatively poor correlation between Two tests, serum cancer antigen 125
visual diagnosis and confirmed histology. For (CA 125) and magnetic resonance imaging
example, microscopic endometrial lesions (MRI), have been closely studied for endo-
may be found in normal-appearing perito-
metriosis, but neither have shown impressive diagnostic accuracy. The use of MRI for diag-nosis of an endometrial cyst is much more accurate than for endometriosis. Although Given the nonspecific symptoms of endome- there is a wealth of interest in the use of triosis, the differential diagnosis is lengthy serum markers to diagnose endometriosis, (Table 2).16 The possibility of malignancy none are accurate enough to be used in must be considered. routine clinical practice. Elevation in levels of CA 125 (i.e., greater than 35 IU per mL), more commonly known for its use in the There are few well-studied clinical maneu- diagnosis or monitoring of ovarian cancer, vers for use in the diagnosis of endome- is of limited diagnostic value; however, given triosis. Signs may be absent or may include its high specificity, CA 125 may be useful as a tender nodules in the posterior vaginal for- marker for disease monitoring and treatment nix, uterine motion tenderness, a fixed and follow-up. In addition, a well-designed meta-retroverted uterus, or tender adnexal masses analysis found that measurement of serum resulting from endometriomas. One study CA 125 levels may be useful in identifying determined the usefulness of clinical signs and patients with infertility who may have severe 596  American Family Physician
www.aafp.org/afp Volume 74, Number 4 ◆ August 15, 2006 endometriosis and could benefit from early cysts but poor diagnostic accuracy for endo-surgical treatment.18 metriosis in general. Empiric diagnosis and One report on the use of serum cancer treatment of endometriosis is reasonable, antigen 19-9 (CA 19-9) in the diagnosis of based on clinical suspicion and presenta-endometriosis found that CA 19-9 has infe- tion. Patients with persistent symptoms after rior sensitivity to CA 125 but may be of some empiric treatment should be referred for
use in determining disease severity.19 There laparoscopy, the preferred method for diag-
is emerging interest in a variety of other nosis of endometriosis.
markers. One relatively small study found
that the cytokine interleukin-6 (at a cutoff treatment
value of 2 pg per mL) may be more sensitive MEDical trEatMEnt 
and specific than CA 125.20 Measurement Standard medical therapies for patients with
of tumor necrosis factor a in the peritoneal endometriosis include analgesics (nonste-
fluid also has shown diagnostic promise, roidal anti-inflammatory drugs [NSAIDs]
with sensitivity and specificity of 1 and 0.89, or acetaminophen), oral contraceptive pills
respectively. However, this test requires an (OCPs), androgenic agents (e.g., danazol
invasive procedure to obtain the fluid. It [Danocrine]),22 progestogens (e.g., medroxy-
may prove useful as an adjunct to less- progesterone acetate [Provera]), gonadotro-
obvious surgical diagnosis.
pin-releasing hormone analogues (GnRHas; Transvaginal ultrasonography has been e.g., leuprolide [Lupron], goserelin [Zola- proven useful in the diagnosis of retroperi- dex], triptorelin [Trelstar Depot], nafare- toneal and uterosacral lesions, but it does not lin [Synarel]), and antiprogestogens (e.g., accurately identify peritoneal lesions or small gestrinone). Table 323 lists the indications endometriomas.21 Computed tomography and standard dosages for medications used (CT) has not been studied rigorously or pro- in the treatment of endometriosis. Figure 2 moted as a diagnostic imaging modality.
presents a decision tree for treatment of endometriosis in select patients.
Although the use of NSAIDs for pain relief There are no sufficiently sensitive and spe- seems logical, their effectiveness has not cific signs and symptoms or diagnostic tests been studied well or compared with other for the clinical diagnosis of endometriosis, treatments. For empiric medical therapy, and no diagnostic strategy is supported by OCPs and medroxyprogesterone acetate evidence of effectiveness. The American Col- have apparent therapeutic equivalence and lege of Obstetricians and Gynecologists rec- should be used as first-line therapies.24-26 ommends a pretreatment diagnostic strategy Many sources support the empiric use to exclude other causes of pelvic pain such as of GnRHas for treatment of the pain asso-chronic pelvic inflammatory disease, fibroid ciated with endometriosis;27 however, a tumors, and ovarian cysts.15 Nongyneco- systematic review found them to be no logic causes of pain also should be excluded. more effective than OCPs or progestogens24 Pelvic and rectal examinations should be (online Table A). Furthermore, GnRHas performed, although the yield of the physical can have hypoestrogenic side effects.28 examination is low. Findings of a retroverted These side effects may be alleviated some-uterus, decreased uterine mobility, cervical what with add-back therapy (i.e., replace-motion tenderness, and tender uterosacral ment of hormones blocked by the action of nodularity are suggestive of endometriosis GnRHas) without diminishing the effect of when present, but these findings often are the GnRHa; however, the optimal method of absent. Laboratory tests and radiologic exam- add-back therapy has not been established.27 inations usually are not warranted. Measure- One small study found the levonorgestrel- ment of CA 125 levels may be useful for releasing intrauterine system (Mirena) to monitoring disease progress, and MRI has be effective in postoperative treatment for a high sensitivity in detecting endometrial dysmenorrhea.29 August 15, 2006 ◆ Volume 74, Number 4 www.aafp.org/afp American Family Physician  597
incidence of recurrent symptoms; women No randomized controlled trials (RCTs) have who had only hysterectomy had a 62 percent evaluated ablation of endometrial deposits incidence of recurrent symptoms.34alone. Ablation of endometrial deposits with or without laparoscopic uterine nerve abla- tion decreases pain (online Table B).30,31 Referral is required for definitive diagnosis Presacral neurectomy, a procedure in of endometriosis by laparoscopy or lapa- which the sympathetic nerves from the uterus rotomy and biopsy, or for surgical ablation. are divided, may decrease midline abdominal Medical treatment with GnRHas or danazol pain.31 Laparoscopic surgery with ablation (if the use of OCPs or progestogens proves of endometrial deposits also may increase ineffective) may be expensive with many fertility in women with endometriosis.32 No possible side effects, and these therapies may systematic reviews or meta-analyses have be outside the range of usual primary care compared laparoscopic drainage and lapa- pharmacotherapy. Physicians experienced roscopic cystectomy for the treatment of in the use of GnRHas and danazol may be ovarian endometriomas. One RCT found comfortable prescribing such medications; cystectomy to be superior to drainage in pain otherwise, referral is appropriate.
relief at two years.33 Hysterectomy and bilateral salpingo- oophorectomy are definitive treatments for The natural history of endometriosis sug-endometriosis, although there are no RCTs gests that the disease may stabilize or resolve to support this. In a retrospective analysis of on its own. In a small study that random-women 10 years after hysterectomy and bilat- ized patients with endometriosis to pro- eral salpingectomy, there was a 10 percent gestin or placebo, follow-up laparoscopy Depot MDPA (Depo-Provera) 150 mg intramuscularly every three months 30 to 100 mg daily, given oral y 0.02 to 0.03 mg ethinyl estradiol and 0.15 mg desogestrel daily (cyclical y) for six months* Levonorgestrel intrauterine Pain relief after Intrauterine system Can be placed easily in primary care setting Gonadotropin-releasing hormone 3.75 mg of leuprolide injected every four Expensive; significant analogues (e.g., goserelin weeks or 3.6 mg of goserelin implanted [Zoladex], leuprolide [Lupron], subcutaneously for six months triptorelin [Trelstar Depot]) Nafarelin (Synarel) 200 mcg intranasal y twice daily for six months Expensive; significant Danazol (Danocrine) 200 mg given oral y three times daily; 400 mg Significant androgenic given oral y twice daily for six months 2.5 mg given oral y twice weekly for six months MDPA = medroxyprogesterone acetate; OCPs = oral contraceptive pil s. *—In one study, combined OCPs were given continuously for two years.23 598  American Family Physician
www.aafp.org/afp Volume 74, Number 4 ◆ August 15, 2006 Endometriosis suspected based on history and physical examination of Medicine. He received his medical degree from the University of North Carolina School of Medicine, Durham, and completed a residency at the Lynchburg Family Medicine Residency Program.
Fertility not desired Infertility (other causes DAVID C. SLAWSON, M.D., is the B. Lewis Barnett, Jr., excluded [see Table 2]) professor of family medicine at the University of Virginia School of Medicine. He also is director and founder of Oral contraceptive pills the Center for Information Mastery at the University or progestogens (with or of Virginia and holds a joint appointment as professor without simple analgesics) in the Department of Health Evaluation Sciences. Dr. Slawson received his medical degree from the University Surgical excision of Michigan Medical School, Ann Arbor, and completed a family medicine residency at the University of Virginia School of Medicine. Gonadotropin-releasing Address correspondence to Anne L. Mounsey, M.D., hormone analogues (with or Dept. of Family Medicine, University of Virginia School without add-back therapy) of Medicine, P.O. Box 800729, Charlottesville, VA 22908. Reprints are not available from the authors. Author disclosure: Nothing to disclose.
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3. Mahmood TA, Templeton A. Prevalence and genesis of endometriosis. Hum Reprod 1991;6:544-9.
Hysterectomy and oophorectomy 4. Laufer MR, Goitein L, Bush M, Cramer DW, Emans SJ. Prevalence of endometriosis in adolescent girls with chronic pelvic pain not responding to conventional therapy. J Pediatr Adolesc Gynecol 1997;10:199-202.
Figure  2.  Steps to consider for treatment of 5. Sangi-Haghpeykar H, Poindexter AN III. Epidemiology
women with endometriosis.
of endometriosis among parous women. Obstet Gyne- after one year showed that regardless of the col 1995;85:983-92.
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progression of their endometriosis, 25 per- 7. Darrow SL, Vena JE, Batt RE, Zielezny MA, Michalek cent had disease resolution, and 25 percent AM, Selman S. Menstrual cycle characteristics and the were unchanged.35 Endometriosis may recur risk of endometriosis. Epidemiology 1993;4:135-42.
after surgery whether or not the patients are 8. Cramer DW, Wilson E, Stil man RJ, Berger MJ, Belisle S, Schiff I, et al. The relation of endometriosis to menstrual treated with estrogen replacement. Likewise, characteristics, smoking, and exercise. JAMA 1986; postmenopausal women may develop endo- metriosis if they use hormone therapy.
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10. Parazzini F, Ferraroni M, Bocciolone L, Tozzi L, Rubessa ANNE L. MOUNSEY, M.D., is assistant professor of family S, La Vecchia C. Contraceptive methods and risk of medicine at the University of Virginia School of Medicine, pelvic endometriosis. Contraception 1994;49:47-55.
Charlottesvil e. She graduated from St. Thomas' Hospital 11. Cramer DW, Missmer SA. The epidemiology of endo- School of Medicine, London, and completed her post- metriosis. Ann N Y Acad Sci 2002;955:11-22.
graduate training in family medicine at Barnet Hospital, 12. Kuohung W, Jones GL, Vitonis AF, Cramer DW, Ken- London, and John Radcliffe Hospital, Oxford.
nedy SH, Thomas D, et al. Characteristics of patients with endometriosis in the United States and the United ALEX WILGUS, M.D., is a faculty member and director Kingdom. Fertil Steril 2002;78:767-72.
of patient care at the Lynchburg (Va.) Family Medicine 13. Zondervan KT, Yudkin PL, Vessey MP, Dawes MG, Bar- Residency Program, and he is clinical assistant professor low DH, Kennedy SH. Patterns of diagnosis and referral of family medicine at the University of Virginia School in women consulting for chronic pelvic pain in UK August 15, 2006 ◆ Volume 74, Number 4 www.aafp.org/afp American Family Physician  599
primary care. Br J Obstet Gynaecol 1999;106:1156-61.
progestagens for pain associated with endometriosis. 14. Barnhart K, Dunsmoor-Su R, Coutifaris C. Effect of Cochrane Database Syst Rev 2000;(2):CD002122.
endometriosis on in vitro fertilization. Fertil Steril 2002; 26. Vercel ini P, Cortesi I, Crosignani PG. Progestins for symptomatic endometriosis: a critical analysis of the 15. ACOG Committee on Practice Bul etins—Gynecology. evidence. Fertil Steril 1997;68:393-401.
ACOG practice bul etin. Medical management of endo- 27. Prentice A, Deary AJ, Goldbeck-Wood S, Farquhar C, metriosis. Number 11, December 1999 (replaces Tech- Smith SK. Gonadotrophin-releasing hormone analogues nical Bul etin Number 184, September 1993). Clinical for pain associated with endometriosis. Cochrane Data- management guidelines for obstetrician-gynecologists. base Syst Rev 1999;(2):CD000346.
Int J Gynaecol Obstet 2000;71:183-96.
28. Vercel ini P, Trespidi L, Colombo A, Vendola N, Marchini 16. American College of Obstetrics and Gynecology. M, Crosignani PG. A gonadotropin-releasing hormone Chronic pelvic pain. ACOG technical bul etin no. 223. agonist versus a low-dose oral contraceptive for pel- Washington, D.C.: American Col ege of Obstetrics and vic pain associated with endometriosis. Fertil Steril Gynecology, 1996:3.
17. Matorras R, Rodriguez F, Pijoan JI, Soto E, Perez C, 29. Vercel ini P, Frontino G, De Giorgi O, Aimi G, Zaina B, Ramon O, et al. Are there any clinical signs and symp- Crosignani PG. Comparison of a levonorgestrel-releas- toms that are related to endometriosis in infertile ing intrauterine device versus expectant management women? Am J Obstet Gynecol 1996;174:620-3.
after conservative surgery for symptomatic endome- 18. Mol BW, Bayram N, Lijmer JG, Wiegerinck MA, Bongers triosis: a pilot study. Fertil Steril 2003;80:305-9.
MY, van der Veen F, et al. The performance of CA-125 30. Jacobson TZ, Barlow DH, Garry R, Koninckx P. Lapa- measurement in the detection of endometriosis: a roscopic surgery for pelvic pain associated with endo- meta-analysis. Fertil Steril 1998;70:1101-8.
metriosis. Cochrane Database Syst Rev 2001;(2): 19. Harada T, Kubota T, Aso T. Usefulness of CA19-9 versus CA125 for the diagnosis of endometriosis. Fertil Steril 31. Proctor ML, Latthe PM, Farquhar CM, Khan KS, John- son NP. Surgical interruption of pelvic nerve pathways 20. Bedaiwy MA, Falcone T. Laboratory testing for endo- for primary and secondary dysmenorrhoea. Cochrane metriosis. Clin Chim Acta 2004;340:41-56.
Database Syst Rev 2005;(4):CD001896.
21. Brosens I, Puttemans P, Campo R, Gordts S, Brosens J. 32. Jacobson TZ, Barlow DH, Koninckx PR, Olive D, Far- Non-invasive methods of diagnosis of endometriosis. quhar C. Laparoscopic surgery for subfertility associ- Curr Opin Obstet Gynecol 2003;15:519-22.
ated with endometriosis. Cochrane Database Syst Rev 22. Selak V, Farquhar C, Prentice A, Singla A. Danazol for pelvic pain associated with endometriosis. Cochrane 33. Beretta P, Franchi M, Ghezzi F, Busacca M, Zupi E, Bolis Database Syst Rev 2001;(4):CD000068.
P. Randomized clinical trial of two laparoscopic treat- 23. Vercel ini P, Frontino G, De Giorgi O, Pietropaolo G, ments of endometriomas: cystectomy versus drainage Pasin R, Crosignani PG. Continuous use of an oral and coagulation. Fertil Steril 1998;70:1176-80.
contraceptive for endometriosis-associated recurrent 34. Namnoum AB, Hickman TN, Goodman SB, Gehl- dysmenorrhea that does not respond to a cyclic pill bach DL, Rock JA. Incidence of symptom recurrence regimen. Fertil Steril 2003;80:560-3.
after hysterectomy for endometriosis. Fertil Steril 24. Moore J, Kennedy S, Prentice A. Modern combined oral contraceptives for pain associated with endometriosis. 35. Cooke ID, Thomas EJ. The medical treatment of Cochrane Database Syst Rev 1997;(4):CD001019.
mild endometriosis. Acta Obstet Gynecol Scand Suppl 25. Prentice A, Deary AJ, Bland E. Progestagens and anti- 600  American Family Physician
www.aafp.org/afp Volume 74, Number 4 ◆ August 15, 2006 TABLE A (ONLINE ONLY) Women of reproductive age, Pain relief, side effects No significant difference in pain six compared with goserelin surgical y diagnosed/ primary and months posttreatment; significantly secondary health care settings more side effects with goserelin Progestogens and anti- Premenopausal women, Pain relief, resolution Equivalent to other medical therapies progestogensA2,A3 laparoscopical y diagnosed/ of endometriotic for pain (e.g., danazol [Danocrine]), primary and secondary health implants, side effects, therefore likely effective; scant good GnRHas compared with Premenopausal women, Pain relief and side More effective than placebo; high laparoscopical y diagnosed, dropout rates in placebo group between 18 and 50 years of age/gynecologic outpatient clinics Premenopausal women, Pain relief and side Similar effectiveness as other medical with other medical laparoscopical y diagnosed, treatments (OCPs, gestrinone, between 18 and 50 years of age/ danazol); gestrinone possibly more gynecologic outpatient clinics effective; OCPs less effective for dysmenorrhea GnRHas compared with Premenopausal women, Pain relief and side Similar effectiveness; fewer side GnRHas plus add-back laparoscopical y diagnosed, effects with add-back hormone between 18 and 50 years of age/ gynecologic outpatient clinics Women of reproductive age, Subjective symptom Significantly more effective than surgical y confirmed diagnosis/ relief, objective disease placebo after six months' therapy settings not specified (systematic improvement, side but with significant side effects effects, compliance, (e.g., weight gain, acne) disease recurrence Preoperative hormonal Various populations/settings not Pain relief, disease Significant reduction in objective specified (systematic review of recurrence, pregnancy disease extent scores, but insufficient endometriosis surgery rates, adverse effects evidence to support use; no evidence compared with surgery of decreased disease recurrence or improved pregnancy rates Hormonal suppression Various populations/settings not Pain relief, disease No benefit; insufficient evidence. No after endometriosis specified (systematic review of recurrence, pregnancy evidence of decreased recurrence or surgery compared with improved pregnancy rates Ovulation suppression for Women with visual y diagnosed Pregnancy, adverse Not beneficial for improvement of disease who did not conceive subfertility; multiple side effects subfertility compared after at least 12 months of with placebo, no unprotected intercourse/settings treatment, or danazolA8 not specified (systematic review) Parous women with moderate to Pain relief one year after 10 percent recurrence of moderate to intrauterine system severe dysmenorrhea who were severe dysmenorrhea in treatment undergoing surgery/tertiary care group compared with 45 percent in dysmenorrhea after OCPs = oral contraceptive pil s; GnRHas = gonadotropin-releasing hormone analogues. Information from references: A1: Moore J, Kennedy S, Prentice A. Modern combined oral contraceptives for pain associated with endometriosis. Cochrane Database Syst Rev 1997;(4):CD001019.
A2: Prentice A, Deary AJ, Bland E. Progestagens and anti-progestagens for pain associated with endometriosis. Cochrane Database Syst Rev 2000;(2):CD002122.
A3: Vercel ini P, Cortesi I, Crosignani PG. Progestins for symptomatic endometriosis: a critical analysis of the evidence. Fertil Steril 1997;68:393-401.
A4: Prentice A, Deary AJ, Goldbeck-Wood S, Farquhar C, Smith SK. Gonadotrophin-releasing hormone analogues for pain associated with endome-triosis. Cochrane Database Syst Rev 1999;(2):CD000346.
A5: Vercel ini P, Trespidi L, Colombo A, Vendola N, Marchini M, Crosignani PG. A gonadotropin-releasing hormone agonist versus a low-dose oral contraceptive for pelvic pain associated with endometriosis. Fertil Steril 1993;60:75-9.
A6: Selak V, Farquhar C, Prentice A, Singla A. Danazol for pelvic pain associated with endometriosis. Cochrane Database Syst Rev 2001;(4):CD000068.
A7: Yap C, Furness S, Farquhar C. Pre and post operative medical therapy for endometriosis surgery. Cochrane Database Syst Rev 2004;(3):CD003678.
A8: Hughes E, Fedorkow D, Col ins J, Vandekerckhove P. Ovulation suppression for endometriosis. Cochrane Database Syst Rev 2003;(3):CD000155.
A9: Vercellini P, Frontino G, De Giorgi O, Aimi G, Zaina B, Crosignani PG. Comparison of a levonorgestrel-releasing intrauterine device versus expectant management after conservative surgery for symptomatic endometriosis: a pilot study. Fertil Steril 2003;80:305-9. August 15, 2006 ◆ Volume 74, Number 4 www.aafp.org/afp American Family Physician  i
Systematic review of LUNAB1 LUNA with ablation was not endometriosis and superior to ablation alone.
Systematic review that included one Increased pain relief LUNA was used with ablation, study of laparoscopic surgery and LUNA endometriosis and so benefit cannot be compared with no treatmentB2 Systematic review of presacral neurectomy No overall difference Women with midline with ablation compared with ablation endometriosis and abdominal pain had a significant decrease in pain.
Systematic review of two RCTs that Infertile women 39 years Increase in ongoing Both studies had evaluated fertility rates after laparoscopic of age with minimal or pregnancy and live methodologic flaws.
ablation of endometrial depositsB3 mild endometriosis LUNA = laparoscopic uterine nerve ablation; RCT = randomized control ed trial. Information from references: B1: Proctor ML, Farquhar CM, Sinclair OJ, Johnson NP. Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev 2005;(4):CD001896.
B2: Jacobson TZ, Barlow DH, Garry R, Koninckx P. Laparoscopic surgery for pelvic pain associated with endometriosis. Cochrane Database Syst Rev 2001;(2):CD001300.
B3: Jacobson TZ, Barlow DH, Koninckx PR, Olive D, Farquhar C. Laparoscopic surgery for subfertility associated with endometriosis. Cochrane Database Syst Rev 2002;(4):CD001398. ii  American Family Physician
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