Dominyka Grinciūtė1, Ernestas Frolovas2
1Vilnius University, Faculty of Medicine, Vilnius, Lithuania
2Vilnius University Hospital Santaros Klinikos, Obstetrics and Gynecology department, Vilnius, Lithuania
Abstract
Background and aim. Endometriosis is an inflammatory disease that highly decreases the quality of life. The gold standard of diagnosis is considered laparoscopy with tissue biopsy, which can often lead to excess surgical interventions. To this day there is an ongoing discussion about the best treatment for endometriosis, which has led to multiple different guidelines and no clear conclusion. The aim of this review is to discuss whether diagnostic laparoscopy can be safely replaced by non-surgical imaging techniques and to compare different treatment guidelines for endometriosis.
Materials and methods. To evaluate whether transvaginal ultrasound and magnetic resonance imaging can take the role of diagnostic laparoscopy with tissue biopsy, the literature research using PubMed and Google Scholar databases was performed. We also reviewed different endometriosis treatment algorithms to try and depict the best treatment method of today.
Results. Radiological endometriosis diagnosis although highly sensitive and specific does depend on the disease location. Nevertheless, it should be the primary choice for diagnosis as it carries less risk for the patient. Most of the treatment algorithms are based on the main symptoms: pain and infertility. The guidelines agree that medical therapy
should be the primary choice of treatment. However, surgery is still irreplaceable while removing already existing endometriotic lesions.
Conclusion. Non-surgical diagnosis can safely replace diagnostic laparoscopy with tissue biopsy in diagnosing endometriosis. Pharmaceutical therapy is the first choice for treatment when the primary symptom is pain. If the main complaint is infertility treatment should depend on the size of the endometrioma and fertility.
Keywords: peritoneal endometriosis, endometriomas, transvaginal sonography, magnetic resonance imaging, firstline therapy.
https://doi.org/10.53453/ms.2023.5.2
Literature review: diagnostic and treatment challenges of
endometriosis in premenopausal women
Dominyka Grinciūtė
1
, Ernestas Frolovas
2
1
Vilnius University, Faculty of Medicine, Vilnius, Lithuania.
2
Vilnius University Hospital Santaros Klinikos, Obstetrics and Gynecology department, Vilnius, Lithuania
Abstract
Background and aim. Endometriosis is an inflammatory disease that highly decreases the quality of life. The gold
standard of diagnosis is considered laparoscopy with tissue biopsy, which can often lead to excess surgical
interventions. To this day there is an ongoing discussion about the best treatment for endometriosis, which has led to
multiple different guidelines and no clear conclusion. The aim of this review is to discuss whether diagnostic
laparoscopy can be safely replaced by non-surgical imaging techniques and to compare different treatment guidelines
for endometriosis.
Materials and methods. To evaluate whether transvaginal ultrasound and magnetic resonance imaging can take the
role of diagnostic laparoscopy with tissue biopsy, the literature research using PubMed and Google Scholar databases
was performed. We also reviewed different endometriosis treatment algorithms to try and depict the best treatment
method of today.
Results. Radiological endometriosis diagnosis although highly sensitive and specific does depend on the disease
location. Nevertheless, it should be the primary choice for diagnosis as it carries less risk for the patient. Most of the
treatment algorithms are based on the main symptoms: pain and infertility. The guidelines agree that medical therapy
should be the primary choice of treatment. However, surgery is still irreplaceable while removing already existing
endometriotic lesions.
Conclusion. Non-surgical diagnosis can safely replace diagnostic laparoscopy with tissue biopsy in diagnosing
endometriosis. Pharmaceutical therapy is the first choice for treatment when the primary symptom is pain. If the main
complaint is infertility treatment should depend on the size of the endometrioma and fertility.
Keywords: peritoneal endometriosis, endometriomas, transvaginal sonography, magnetic resonance imaging, first-
line therapy.
Journal of Medical Sciences. 11 May, 2023 - Volume 11 | Issue 4. Electronic - ISSN: 2345-0592
Medical Sciences 2023 Vol. 11 (4), p. 14-25, https://doi.org/10.53453/ms.2023.5.2
14
1. Introduction
Endometriosis is an inflammatory disease defined as
lesions of endometrial-like tissue outside the uterus.
The condition is associated with infertility and pelvic
pain (2). This topic is important to discuss as it is
estimated to affect about 10% of reproductive-age
women and the main symptoms highly decrease life
quality by damaging personal relationships and
productivity (3). Furthermore, a definitive diagnosis of
endometriosis requires diagnostic laparoscopy with
tissue biopsy. Therefore, the actual prevalence is
uncertain. Also, the average time between the first
symptoms to diagnosis is about seven years; thus, most
of the time, the diagnosis is late (2,4,5).
Endometriosis may manifest with various symptoms
such as dysmenorrhoea, dyspareunia, ovulation pain,
chronic pelvic pain and infertility, or it may also be
asymptomatic. Even in symptomatic cases, it is
challenging to diagnose endometriosis based on
manifestation alone because those are not
pathognomonic symptoms, and they overlap with pelvic
inflammatory disease and irritable bowel symptoms (6).
Historically, there are many mentions of women having
symptoms characteristic of endometriosis. However,
there are two main reasons to consider historical context
critically. Firstly, as mentioned previously,
endometriosis has similar symptoms to irritable bowel
syndrome and pelvic inflammatory disease. The second
reason closely related to the first one is that to this day,
the only definitive diagnostic test for endometriosis is
considered laparoscopy with tissue biopsy, and it started
being performed only recently compared to the first
mentions of endometriosis-like manifestations, which
date more than 4000 years ago (3,6). As the
understanding of the disease changed, it is important to
mention that the first person to diagnose endometriosis
microscopically in 1860 was Karl von Rokitansky (3).
Nevertheless, Cullen was the first to precisely describe
peritoneal endometriosis mentioning ten places in the
pelvis where he had found endometrial-like lesions
(7,8). He also found endometriotic lesions in myomas
and the uterus and called it "adenomyoma" (7). Later,
Sampson described several cases of ovarian
endometrioma, which he called "Perforating
Hemorrhagic (Chocolate) Cysts of the Ovary".
Sampson also proposed implantation theory which
states that a retrograde flow of blood mixed with full
endometrial tissue going through Fallopian tubes into
the peritoneal cavity is the main cause of the disease
(3,7). The celomic theory is another attempt to explain
the cause of endometriosis, except in this theory, the
endometrial tissue does not come from the uterus.
Coelomic metaplasia describes the transformation of
normal peritoneal tissue to ectopic endometrial tissue;
this transformation happens because of hormonal or
immunological triggers (7,9). There are even more
theories, theory of abnormal embryogenesis, stem cell
theory, autoimmune disease, or immune deficiency
theory. The reason for such a variety of possible theories
is that none of the mechanisms can fully explain this
disease (7). Therefore, it is important to discuss today's
diagnostic and treatment standards because with the
changing comprehension of the disease, arising new
theories and genetics playing a role in pathogenesis,
some diagnostic and therapeutic methods may have
outlived their usefulness and others may have just
recently come into play.
2. Materials and Methods
A search was performed using PubMed and Google
Scholar databases using these terms: peritoneal
endometriosis, endometriomas, non-invasive
diagnosis, pharmaceutical therapy and diagnostic
laparoscopy. Only articles in English were included.
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3. Results
3.1. Diagnosis
To this day, diagnostic laparoscopy with tissue biopsy
is considered the gold standard for diagnosing
endometriosis (10). Nevertheless, medical equipment
has immensely improved over the years, so in this part,
the main question is whether laparoscopy is still the
gold standard or maybe some other diagnostic
techniques have caught up with it, thus, allowing
doctors to avoid invasive diagnoses. Only the
diagnosis of superficial and ovarian endometriosis will
be considered in this article. The term superficial
endometriosis in this review includes both superficial
peritoneal lesions and lesions on the ovarian surface.
Also, the term will be used as a synonym for peritoneal
endometriosis as more studies have focused on
superficial peritoneal endometriosis, and superficial
ovarian endometriosis is poorly described; therefore,
many authors chose to use these terms as
synonyms (11).
3.1.1 Anamnesis and clinical examination
Before discussing imaging techniques and other
diagnostic methods, we will concentrate on anamnesis
and clinical examination, which are often neglected.
Often the primary manifestation of endometriosis is
pain which can be dysmenorrhea, dyspareunia or
chronic pelvic pain. However, the pain is not
pathognomonic to endometriosis and can be caused by
non-gynecological conditions. Another common
complaint is infertility. Charles Chapron et al. (2019)
suggest a specific questionnaire to evaluate the
possibility of endometriosis in women (12). According
to the patient's history, all the points in this
questionnaire are indicators of possible endometriosis.
The questionnaire must be detailed and involve the
family history of endometriosis, in utero or early
childhood factors, adolescent history, phenotype,
infertility, pain characteristics, menstrual symptoms,
fatigue syndrome, associated comorbidities, previous
obstetrical history and previous history of pelvic
surgery (12). When considering clinical examination,
it is best to perform it during menstruation as this
improves detection. The physicians should look for
bluish lesions on the vaginal fornix suggesting
superficial endometriosis. Also, palpable nodules of
the rectovaginal wall, posterior cul-de-sac, uterosacral
ligaments and retroverted uterus may point to deep
infiltrative endometriosis. If adnexal masses are
detected, ovarian endometrioma should be considered.
However, normal physical examination does not
exclude endometriosis diagnosis. Therefore, it should
be done at least twice if a woman is complaining of
pain or infertility. The first time it may be done by a
physician who is not an expert in endometriosis as a
routine examination. If, after this examination, the
results are normal, then transvaginal ultrasound should
be performed; again, the physician sonographer does
not have to be an expert in the field of endometriosis.
Finally, if the results after the clinical examination and
initial ultrasound are normal, then both of these steps
should be repeated by an expert. Nevertheless, if
endometriosis is found by clinical examination, the
extent of it must be evaluated by more precise methods
such as transvaginal ultrasound, magnetic resonance
tomography (MRI) or diagnostic laparoscopy. The
same methods should be used if the clinical
examination is normal, as this does not exclude the
diagnosis. (12,13).
3.1.2 Imaging or diagnostic laparoscopy
Before comparing imaging techniques with diagnostic
laparoscopy, it is important to mention why it would
be beneficial to avoid surgery. First of all, surgical
intervention laparoscopy carries certain risks, such as
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16
pelvic organ injury (about 2% risk), damage to major
blood vessels (0,001% risk) and very small,
nonetheless, existing risk of mortality (0,0001%). It
also requires full anesthesia and may cause adhesions
after the surgery. Furthermore, laparoscopy is
expensive, and even though it is considered the gold
standard for the diagnosis of endometriosis, only about
one-third of the women who undergo diagnostic
laparoscopy are diagnosed with endometriosis (1,14).
Finally, the sensitivity and specificity of laparoscopy
highly depend on the surgeon's skills and must be
followed by histological evaluation. However, it is
essential to mention that diagnostic laparoscopy can be
extended to remove endometriotic lesions, managing
two procedures simultaneously (1,13). Therefore, it is
critical to determine whether any non-invasive
imaging techniques have enough sensitivity and
specificity to diagnose endometriosis and single out
the cases where diagnostic laparoscopy would be
necessary.
3.1.3 Transvaginal ultrasound
Considering transvaginal ultrasound (TVUS), the
diagnosis process should be divided into two parts
first-line diagnostic investigation and second-line
diagnostic investigation. The first-line diagnostic
investigation consists of a physical examination and
TVUS. During the ultrasound, the operator should
evaluate the uterus and ovaries as well as the adnexa
and the mobility of the uterus (normal, reduced or
fixed). The second-line diagnostic investigation
involves targeted pelvic examination and TVUS
performed by an expert clinician along with pelvic
MRI (13,15). Supposing endometriosis is not detected
during the first-line investigation. In that case, it is
vital to investigate by an expert because the variance
of endometriotic lesions and distorted anatomy caused
by adhesions and fibrosis complicates sonographic
evaluation (16). Ovarian endometrioma and
adenomyosis are probably the easiest forms of
endometriosis to diagnose by TVUS. In
premenopausal women, it can be seen as cystic lesions
with ground glass echogenicity (17). The challenge
arises if an endometrioma is smaller than 2 cm, as it
may be overlooked. It can also be confused with
corpus luteum or luteum cysts, ovarian fibroid, tubo-
ovarian abscess, teratoma or dermoid cystadenoma.
Also, it is imperative not to mistake malignant tumors
for endometrioma in postmenopausal women (11,13).
For differential diagnosis of endometrioma, cystic
corpus luteum and malignant tumor, Color Doppler
can be helpful as it shows the vascular flow (17,18).
Corpus luteum cyst typically has a circular flow, and
malignancy should be suspected if there is the
presence of vessels in papillations (17). Also, for
TVUS diagnosis, the International Ovarian Tumor
Analysis (IOTA) group's simple descriptors perform
well in differentiating adnexal masses suspected to be
endometrioma (19). Alternatively, #Enzian
classification may be used for TVUS endometrioma
diagnosis as well as for diagnosing pelvic
endometriosis (20). Patients with endometriomas are
likely to have deep endometriotic lesions; therefore,
they should be evaluated for DE (13).
In 2016 Vicki Nisenblas et al. meta-analysis TVUS
qualified as a SpPin triage test, with 93% sensitivity
and 96% specificity, and approached the criteria for
replacement and SnNout triage test (1). Nonetheless,
for pelvic endometriosis, TVUS showed high
heterogeneity in sensitivity and specificity. The mean
sensitivity was estimated to be 65% and specificity
95%, thus not qualifying as a replacement test but
approaching the criteria for SpPin triage test (Table 1)
(1). The possibility of diagnosis highly depends on the
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site of endometriosis; also, some newer publications
suggest that TVUS can replace diagnostic surgery,
which may be attributed to improved technology and
skills. However, none of the publications specifies on
TVUS models they were using, and clinicians' skills
are complicated to determine objectively (1,17).
3.1.4 Magnetic resonance imaging
Magnetic resonance imaging (MRI) is typically
considered the second-line investigation of
endometriosis because of the cost and smaller
availability. However, it has better diagnostic
accuracy than TVUS in detecting pelvic endometriosis
according to some authors and is less operator-
dependent (21). Considering the preparation for MRI,
the patient should fast for about 2 – 3 hours prior to the
examination only if evaluating deep pelvic
endometriosis. Some studies showed more precise
results if the examination is performed not during
menses; however, these results differ in different
studies; therefore, it is not considered a strong
recommendation, but it may be helpful if MRI is not
performed during menses. Fat-suppressed T1-
weighted sequence in some studies was considered the
gold standard for diagnosing endometriomas. It is also
helpful for differential diagnosis from dermoids which
are fat-containing lesions; therefore, they will be ruled
out (22,23). T2-weighted seuence without fat
suppression should be used for pelvic endometriosis
detection (23).
In Vicky Nisenblas et al. (2016) meta-analysis MRI
for endometriomas showed 95% sensitivity and 91%
specificity, meeting the criteria for a replacement test
and SnNout triage test as well as approaching the
criteria for SpPin test (1). As for pelvic endometriosis,
the sensitivity was only 79% and specificity 72%,
which did not meet or approach any of the criteria
(Table 2) (1).
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None of the tests was accurate enough for the overall
diagnosis of endometriosis. However, depending on
the sight and type of the endometriosis TVUS and
MRI can replace diagnostic laparoscopy (1,24).
Furthermore, according to the 2022 Guideline of
European Society of Human Reproduction and
Embryology (ESHRE), laparoscopy is no longer the
gold standard and is only recommended in cases where
imaging results were negative or empirical treatment
was either unsuccessful or inappropriate (25).
3.2. Treatment
When considering the treatment of endometriosis,
there are two main categories: non-surgical treatment,
which involves analgesics as well as hormonal
treatment, and surgical treatment. Hormonal therapy is
mainly based on ovary suppression as endometriotic
lesions are estrogen-dependent (3). In this part, we will
not go into specifics of different treatment options.
The main goal is to discuss for which patients only
non-surgical treatment will suffice and in which cases
surgery is necessary.
3.2.1. Pharmaceutical and empirical treatment
There are a few limitations of the existing
pharmaceutical treatment. Firstly, it is mainly used for
pain management and has little effect on reducing
endometriotic lesions. Also, no medical therapy today
is effective enough to treat already existing
endometriomas and does not affect pelvic adhesions
(3,26,27). Also, almost all of these treatment options,
except for non-steroidal anti-inflammatory drugs,
dydrogesterone and dienogest, inhibit ovulation;
therefore, are not helpful for women trying to conceive
(3,28). However, pharmaceutical treatment should be
the primary choice as both diagnostic laparoscopy and
endometriosis surgery carries certain risks. The main
surgical complications of removing endometriomas
include diminished ovarian reserve, which may lead to
infertility or premenopause, as well as basic
laparoscopic complications (3,29). Women
experiencing only pain with no other symptoms and no
other indications for surgery should be considered for
medical therapy without histological endometriosis
confirmation. However, effective empirical therapy
does not prove endometriosis diagnosis (3). Medical
therapy can be divided into first-line and second-line.
The first-line consists of combined oral contraceptives
and progestins with or without NSAIDs which can be
prescribed empirically. The Second-line treatment
consists of GnRH analogs and aromatase inhibitors
which are only prescribed if the first-line therapy is
ineffective or not tolerated as they have more side
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effects and GnRH analogs need add-back therapy after
six months of use (3,28). Empirical therapy should
usually start when a patient complains of
dysmenorrhea, and an initial examination is performed
without any diagnosis of pelvic pathology. NSAIDs
and/or hormonal suppression are prescribed as, most
of the time, it is primary dysmenorrhea. If symptoms
do not improve in 3 – 6 months with empirical
treatment, secondary dysmenorrhea should be
suspected; which most common cause is
endometriosis (30). S. Chaician et al. (2017)
conducted a systematic review and meta-analysis
comparing surgical and medical therapy for patients
experiencing pain (31). No statistically significant
difference was seen between pharmaceutical therapy
and surgery. However, the author emphasizes that
studies were based on follow-up, and all patients that
did not come back to clinicians were considered cured.
Nevertheless, this assumption is not necessarily valid,
and there is a high chance that these patients went to
other clinics or decided to seek alternative treatment
methods. Therefore, it is quite difficult to evaluate the
exact impact of both medical therapy and surgical
treatment (31). Some experts suggest that starting
medical therapy with progestins should be the primary
choice, especially Dienogest, as it has shown
promising results in reducing pain symptoms and
increasing overall life quality. Dienogest also has
advantages over combined oral contraceptives, such as
not having an estrogen component that may stimulate
the disease as well as not suppressing ovaries (32–34).
An overview of Cochrane reviews also concluded that
current data is insufficient to evaluate the effectiveness
of oral contraceptives compared to placebo (35).
3.2.2. Ovarian endometriosis: pain and infertility
For many women suffering from endometriosis pain is
the first symptom. S. Cosma et al. (2020) suggest an
algorithm based on the two primary symptoms pain
and infertility (which will be discussed later) when
considering the treatment of endometrioma (36).
According to this algorithm, if pain is present, then the
size of the endometrioma should be considered. If it is
smaller than 3 cm, then medical therapy is the first
choice. A fertility scan should be conducted if an
endometrioma is larger than 3 cm. In the case of a
normal fertility scan, the first choice is medical
therapy. If it fails, then surgery should be considered.
Given that the fertility scan is abnormal, the patient
should be referred to a specialized psychologist for
counseling, and further treatment choices should be
based on pain management and infertility (36). In this
algorithm, if a fertility scan is normal, the first choice
is always medical therapy. However, C. E. Miller et al.
(2021) suggested an algorithm in which the central
aspect dividing surgical and non-surgical patients is
the size of an endometrioma when pain is present (37).
If endometrioma is 3 cm or smaller, medical therapy
should be chosen. In the case of endometrioma being
larger than 3 cm, the first choice should be ovarian
cystectomy (37). Both articles have analyzed either
multiple studies or already approved guidelines and
still present differences in their suggested algorithms,
thus, presenting the main issue of endometriosis
treatment – the lack of an equal systematic approach.
C. E. Miller et al. (2021) suggest this algorithm if
fertility is desired. If an endometrioma is 3 – 4 cm or
smaller, then pregnancy should be attempted without
removal of an endometrioma because there is a high
chance that this size endometrioma will not cause
fertility problems (37). Furthermore, if surgery is
performed, it can damage the ovarian reserve.
However, if an endometrioma is larger than 3 – 4 cm,
ovarian cystectomy should be performed due to the
risk of rupture or torsion, and then pregnancy should
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20
be attempted. Assistant reproductive technologies
should be considered if pregnancy attempts are
unsuccessful despite 1 – 1.5 years of trials (26,38).
Another question to be considered if endometrioma
was not removed because of the small size is whether
there is a chance of endometrioma rupturing during
egg retrieval as this may cause pelvic infection or
abscess. Also, does endometrioma negatively affects
atrial follicle count compared to the non-affected side.
Finally, the last question C. E Miller et al. suggest
asking is whether there is a high risk of implantation
failure caused by endometrioma. If any of these last
questions are positive, then ovarian cystectomy should
be considered (26). S. Cosma et al. (2020) suggest a
similar algorithm for infertility treatment (36). If
infertility is the main symptom, a fertility scan should
be conducted; if it is normal, the patient should attempt
natural conception. If natural conception is
unsuccessful, assisted reproductive technology can be
used. In the case of an abnormal fertility scan, assisted
reproductive technology is considered the only choice
(36). For patients who do not wish to conceive or have
another endometrioma in the same ovary, unilateral
oophorectomy may be suggested as it is the best
preventative measure for endometrioma
recurrence (38).
3.2.3. Peritoneal endometriosis
R. M. Kho et al. (2018) compared major gynecological
society guidelines and presented a superficial
endometriosis treatment algorithm based on the main
symptoms (39). If the patient's primary symptom is
pain, then medical therapy is the first choice. If the
primary symptom is infertility, then assisted
reproductive techniques should be considered. If a
woman suffers from both symptoms, she is eligible for
medical therapy and assisted reproductive techniques.
Laparoscopic surgery is indicated only when medical
therapy fails in relieving pain and in vitro fertilization
fails twice (39).
3.3. Surgical techniques
When considering surgical treatment, it is important to
remember that incomplete removal of endometriomas
can lead to recurrence, and too aggressive treatment
can cause hormonal imbalance and damage the
ovarian reserve resulting in fertility problems. This is
very important if a small endometrioma is found
accidentally during a routine examination as it may not
cause any symptoms because of the small size;
therefore, surgical removal should be considered more
damaging than therapeutical (26). If surgery was
deemed necessary, then ovarian cystectomy should be
performed instead of drainage and coagulation
because it is considered to have a lower recurrence
rate, better pain relief after surgery and increased
spontaneous pregnancy rates (40–42). If there was a
previous ovarian surgery, the endometriosis surgery
should be considered carefully and individually as
reoperation may lead to reduced ovarian function or
complete loss of the ovary (39). M. F. Shaltout et al.
(2019) conducted a randomized controlled trial
dividing women with endometriomas into four
groups (43). The first group of patients underwent
laparoscopic drainage surgery, the second group had
laparoscopic cystectomy, the third group had
laparoscopic drainage with insertion of Surgicel inside
the remaining ovary, and the fourth group also had the
insertion of Surgicel, but instead of drainage,
laparoscopic cystectomy was performed. The patients
received a two-year follow-up for both recurrence of
endometriomas and ovarian reserve evaluation.
Women who underwent laparoscopic cystectomy and
had Surgicel insertion in the remaining ovary had the
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21
lowest recurrence rate compared to the other groups.
However, the drainage and Surgicel group had the
smallest decrease in ovarian reserve. This study shows
that the best option for recurrence prevention is
laparoscopic cystectomy, and it can be even more
efficient by adding Surgicel. However, it is essential
to evaluate ovarian reserve before surgery as
cystectomy causes higher depletion than drainage
(43). Patients with big endometriomas or challenging
anatomy may benefit from a two- or three-
stage surgical treatment to preserve fertility.
Laparoscopic endometrioma drainage and coagulation
are the first steps in the two-stage approach, followed
by adjuvant GnRH analogue therapy. The third stage
can be carried out if endomerioma persists following
treatment, in which case a second laparoscopy can be
done (44) .
Regarding peritoneal endometriosis, there is still a
debate on which technique is superior as there was
seen no difference in pain, recurrence, or fertility
outcomes after surgery, either ablation or excision
(39,45). Probably the best option when operating
peritoneal endometriosis is to evaluate the depth of the
endometriosis lesion. For more superficial lesions,
ablation may be sufficient, and for deeper ones,
excision should be the first choice as ablation emits
much energy, which damages surrounding
structures (41).
3.1 Medical therapy after surgery
According to some articles, there is no substantial
evidence that post-surgical medical therapy improves
pain after 12 months compared to surgery alone,
though there might be a lesser chance of recurrence if
medical therapy is used post-surgery. Only moderate
evidence shows improved pregnancy rates using
medical therapy after surgery (46,47). However, based
on A. Zakhari et al. (2020) meta-analysis and A. Murji
et al. (2020) literature review and expert commentary,
the use of Dienogest postoperatively significantly
reduces the risk of endometriosis recurrence compared
to those who receive no medical treatment (32,48).
4. Conclusion
Non-surgical diagnosis of endometriosis even though
in some cases highly sensitive and specific is very
dependent on endometriosis location, therefore,
diagnostic laparoscopy cannot be yet fully replaced.
Nevertheless, TVUS and MRI should be the first
choice to avoid excess operations and, therefore,
according to the 2022 ESHRE guideline, it is the
primary choice for diagnosis. One of the shortages we
found in all the research is that the specific models of
TVUS and MRI are not mentioned or compared which
could be helpful to make results more standardized.
Also, for both non-surgical and laparoscopic
diagnostic the importance of a specialist is
emphasized, however, this criteria is fairly difficult to
evaluate objectively. When it comes to treatment the
research and guidelines agree that medical therapy
should always be the first choice, preferably starting
with Dienogest. Surgical treatment should only be
considered if medical therapy fails or the size of an
endometrioma is larger than 3 – 4 cm as medical
therapy most likely will not reduce the size of it and it
has a higher chance of rupture. It is important to
evaluate the ovarian reserve irrespective of the
primary symptom when choosing a surgical technique
for endometriomas as they may impact it differently,
thus, impacting future fertility. The main aspect of
peritoneal endometriosis surgery should be the depth
of the lesion.
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