The treatment of endometriosis should be individualized, assessing the totality of symptoms and the impact that the disease and the proposed treatment will have on the patient’s quality of life. Therapeutics should be aimed at pain management and restoration of reproductive function by removing the tumor implants of endometrial cells and reconstituting the altered pelvic anatomy. No treatment to date has succeeded in eradicating the disease by preventing its progression or recurrence. We must remember that endometriotic lesions can evolve, become stationary or even return.
There is no indication for treatment in asymptomatic endometriosis. Specific treatment of endometriosis should only be considered in cases of pain with impairment of quality of life, in selected cases of infertility and in the presence of complex ovarian masses.
Endometriosis has historically been considered an endocrinological process based on the erroneous belief that low estrogen levels could control the development of the disease. There is no scientific evidence that removal of the pelvic organs and low estrogen levels definitively eliminate the disease. Histologic endometriosis may exceptionally remain active and symptomatic in the presence of low estrogen levels postmenopause and some of these patients will require intervention.
The surgical strategy should be based on each patient’s clinical situation (pain and infertility), age, future reproductive desire and previous treatments.
Medical treatment
Endometriotic lesions are not always the only etiology of pain suffered by patients. Multiple physical and also psychological factors can influence the importance of pain. Pain can mask personality alterations and its psychological burden can reduce the results of treatment. A multidisciplinary team (gynecologist, pain unit specialist, psychologists and psychiatrists) should evaluate such patients.
The initial recommendation to treat pain is medical hormonal treatment to decrease ovulation and estrogen production. In case of lack of response, a diagnosis of certainty should be made by laparoscopic evaluation with histological confirmation of the presence of endometriosis. Medical treatment, based on historical rationale, has focused on the use of medical castration regimens with estrogen-progestogens, danazol and GnRH analogs. Although these drugs can induce temporary quiescence of active lesions at the expense of preventing ovulation and potential fertility, they have proven ineffective, with poorly tolerated side effects and a high rate of recurrences. None has been able to establish superiority over the others in terms of implant reduction, recurrence rate or pregnancy rate.
The use of single progestin anovulatories, especially the use of the levonorgestrel IUD and, since its introduction in 2013, the use of oral Dienogest, can be useful for the symptomatic treatment of endometriosis and even in the long term produce a slight decrease in the size of rectovaginal lesions and endometriomas in women without an immediate desire for offspring and allow avoiding or minimizing the number of surgeries with a low prevalence of side effects.
Most of the authors conclude that there is limited evidence on whether hormonal contraceptives reduce pain after surgery for endometriosis. In spite of this, given the few side effects of this therapy, its use is usually recommended as an indefinite post-surgical treatment for all patients until they reach menopause or when they wish to seek gestation, either naturally or through assisted reproduction techniques.
Surgical Treatment
Nowadays, the laparoscopic approach is considered the ideal way to approach ovarian, peritoneal and deep pelvic endometriosis (with involvement of other organs: rectovaginal, bladder and/or ureteral). Treatment should consist of removal of all endometriotic implants or lesions, which may require partial resection of the bladder, ureter or bowel.
The first surgical approach is crucial to the prognosis. Incomplete treatments reduce the fertility rate and increase the risk of persistence or recurrence.
If deep endometriosis is suspected, laparoscopy is not recommended for the diagnosis or treatment of endometriomas only, but the patient should be referred to Specialized Referral Units for optimal treatment of first intention. In the new endometriosis units run by specialized gynecologists, adequate communication and counseling by colorectal and urological surgeons involved with the disease will also be available.
The literature of the last 25 years estimates a highly variable recurrence rate of 2-47%. This rate is cumulative and increases with a longer follow-up period, so that the youth of the patient proves to be the main factor of recurrence.
Conclusions
Endometriosis has been chosen in some international forums as “the challenge of our time”, because, despite the large amount of scientific information published annually, the etiology or origin of the disease remains unresolved, its pathology is disputed and in many cases there is a lack of consensus on its treatment.
The “magic pill” for the treatment of endometriosis would be one that relieves pain and cures infertility without inhibiting ovulation or menstruation and without side effects. All this would entail a change in the current management of endometriosis, as complex surgery could be abandoned in favor of medical treatment. However, to date, this drug does not exist.
Optimal surgery for deep endometriosis can cure up to 50% of patients and lead to an elimination of symptomatology in 60-95% of cases if performed by properly trained surgeons in specialized multidisciplinary units. In such units women will be able to receive the necessary help to understand this disease, already recognized as incapacitating by our society and administration and in which, despite a successful and complete treatment, the total disappearance of its symptomatology is not always possible.