Clinical Management of Endometriosis

Tommaso Falcone, MD, FRCSC, FACOG

The clinical management of endometriosis is a complex interaction with the patient that requires insight and experience. Paramount in this discussion is the issue of quality of life for the patient and her family. In economic terms the productivity loss from this disease for the woman is double the health care cost. The challenges of managing endometriosis starts with the diagnosis. Although clinical impression can suggest the diagnosis, the large number of other clinical syndromes associated with chronic pelvic pain makes the definitive diagnosis challenging. Ultrasound Imaging is the main stay of non-invasive diagnosis. Although the imaging diagnosis of an endometrioma is straightforward the diagnosis of deeply infiltrating endometriosis (DIE) is not.

The management of an infertile patient with endometriosis is challenging as the benefit of directly treating the disease should be weighed with the success of assisted reproductive technology. The management of chronic pelvic pain that is attributed to endometriosis can be managed effectively medically or surgically. However recurrence is common for both. Endometriosis occurs in many non-reproductive tract organs such as the bowel, urinary tract, abdominal wall and diaphragm. Surgical management in these areas require a high level of skill. The main controversies in the surgical management of endometriosis are whether we ablate or excise a lesion; endometrioma management and the approach to resection of a lesion of the colon or rectum.

There are several unique clinical scenarios that require extra patience and unique insight. The adolescent patient with chronic pelvic pain and endometriosis requires unique insight into the management of a clinical situation that involves family dynamics and a strategy that avoids overtreatment. Recurrent pelvic pain after medical or surgical therapy is common and requires understanding of nuances of the processing of pain by the individual patient. The association of chronic pelvic and endometriosis with signs of sensitization and myofascial pain requires a multidisciplinary approach. In patients with longstanding and persistent endometriosis there is growing concern of a potential association with malignancy. These issues are reviewed in depth in this issue by experienced clinicians.