{"paper_id":"106d902b-a7a6-4dfa-a026-b7a8a045d2ce","body_text":"www.ogscience.org 553\nReview Article\nObstet Gynecol Sci 2018;61(5):553-564\nhttps://doi.org/10.5468/ogs.2018.61.5.553\npISSN 2287-8572 · eISSN 2287-8580\nIntroduction\nEndometriosis is defined as the presence of endometrium-\nlike tissue outside the uterus. Endometriosis causes severe \npain, and/or infertility in reproductive women. The prevalence \nof endometriosis is known to be 2–10% in the reproductive \nage. While there are practice guidelines for endometriosis \nin Western countries, but none in Korea reflecting domestic \nepidemiology and condition. Thus, members of the Korean \nSociety of Endometriosis (KSE) decided to develop guidelines \nfor Korean clinicians.\nTo produce evidence based guideline, we reviewed pub -\nlished guidelines and literatures including international and \ndomestic studies.\nRecommendations are categorizedinto 4 grades (A–D) de -\npending upon the strength of evidence. The grades of recom-\nmendation are: \nA: Meta-analysis or multiple randomized trials.\nB: Large non-randomized trials or case control/cohort studies.\nC: Non analytic studies or case reports/case series.\nD: Expert opinion.\nBackground\n1. Prevalence \nPrevalence of endometriosis is reported to be about 10% of \nreproductive age women, about 20–30% of infertility women, \nand about 40–82% of chronic pelvic pain women [1-3]. A study \non Korean women reported that 1.03–6.7% of patients experi-\nencing gynecologic surgery, 2.5–8.5% of patient who were op-\nerated for chronic pelvic pain, 2.5–45.4% of patient who were \ndiagnosed with infertility, had endometriosis. The prevalence of \nClinical evaluation and management of endometriosis: \nguideline for Korean patients from Korean Society of \nEndometriosis\nHyejin Hwang\n1\n, Youn-Jee Chung\n1\n, Sa Ra Lee\n2\n, Hyun-Tae Park\n3\n, Jae-Yen Song\n1\n, Hoon Kim\n4\n, Dong-Yun Lee\n5\n,  \nEun-Ju Lee\n6\n, Mee-Ran Kim\n1\n, Sung-Tack Oh\n7\nDepartment of Obstetrics and Gynecology, \n1\nCollege of Medicine, The Catholic University of Korea, \n2\nEwha Womans University College of Medicine, \n3\nKorea University College of Medicine, \n4\nSeoul National University College of Medicine, \n5\nSamsung Medical Center, Sungkyunkwan University College \nof Medicine; \n6\nChung-Ang University School of Medicine, Seoul; \n7\nChonnam National University Medical School, Gwangju, Korea\nEndometriosis is one of the most common diseases in reproductive ages, and it affects patients' quality of life and \nfertility. However, few Korean guidelines are available for the evaluation and management of endometriosis. \nKorean Society of Endometriosis reviewed various literatures and trials, and to provide seventy-one evidence-\nbased recommendations. This review presents guidelines for the diagnosis and management of endometriosis with \nemphasis on: it's role in infertility, treatment of recurrence, , asymptomatic women, endometriosis in adolescents and \nmenopausal women, and possible association of endometriosis with cancer. \nKeywords: Endometriosis; Infertility; Pelvic pain; Dysmenorrhea\nReceived: 2017.10.16.   Revised: 2018.03.30.   Accepted: 2018.04.24.\nCorresponding author: Mee-Ran Kim \nDepartment of Obstetrics and Gynecology, College of Medicine, \nThe Catholic University of Korea, 222 Banpo-daero, Seocho-gu, \nSeoul 06591, Korea \nE-mail: mrkim@catholic.ac.kr\nhttps://orcid.org/0000-0003-4492-0768\nArticles published in Obstet Gynecol Sci are open-access, distributed under the terms of \nthe Creative Commons Attribution Non-Commercial License (http://creativecommons.\norg/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, \nand reproduction in any medium, provided the original work is properly cited.\nCopyright © 2018 Korean Society of Obstetrics and Gynecology \n\nwww.ogscience.org554\nVol. 61, No. 5, 2018\nendometriosis varies across studies (grade C) [4-6].\n2. Risk factors\n1) Clinical factors \nClinical risk factors for endometriosis include the following: \nnull parity, short menstruation cycle, long menstruation dura-\ntion, heavy menstruation bleeding, early menarche, family his-\ntory of endometriosis, obstructive uterine anomaly, low body \nmass index, Asian, and diethylstilbestrol exposure in utero [7-9] \n(grade B). \n2) Genetic factors \nIt is known that endometriosis is closely related to genetic fac-\ntors. However, endometriosis follows multi-genetic foci with \nnon-Mendelian heredity [10,11] (grade C).\n3) Environmental factors \nAlthough the relationship between endometriosis and ex -\nposure to endocrine disrupting chemicals has been reported \nrecently, but the mechanism has not been revealed definitely, \nand further studies are needed [12,13] (grade C).\n4) Dietary factors \nStudies between endometriosis and diet have been con -\nducted only on small scale studies or patient control studies. \nConsumption of alcohol, caffeine, fat and red meat, ham, \nand smoking can possibly elevate the risk of endometriosis, \nwhile consumption of green vegetables and fruits lower the \nrisk. Meta-analysis, however, did not show any significance \n[7,14,15] (grade C). \nDiagnosis\n1. Symptoms\n•\t\tClinicians\t should\t suspect\t endometriosis\t when\t patients\t\ncomplain of following symptoms; gynecologic symptoms \n— such as dysmenorrhea, non-cyclic pelvic pain, dyspa -\nreunia, infertility and fatigue accompanied any symptom \nof above, or cyclic non-gynecologic symptoms such as — \ndyschezia, dysuria, hematuria and rectal bleeding, and \nshoulder pain in reproductive age (grade D).\nMany studies reported endometriosis-related symptoms, as \ndysmenorrhea, chronic pelvic pain, deep dyspareunia, cyclic \nbowel symptom, fatigue and infertility [16-18]. However, \nstudies did not provide a predictive value of these symp -\ntoms. In addition to a history of ovarian cysts, irritable bowel \nsyndrome or pelvic inflammatory disease, other symptoms, \nincluding dysmenorrhea in women with infertility, abdomino-\npelvic pain, dysmenorrhea, heavy menstrual bleeding, infertil-\nity, dyspareunia, and post coital vaginal bleeding may indicate \nthe possibility of endometriosis [16,19]. \n2. Clinical examination\n•\t\tClinicians\t should\t perform\t pelvic\t and\t abdominal\t exami-\nnation to all suspected endometriosis patients. When \nvaginal exam is not appropriate, as for a patient with no \nsexual intercourse history, a rectal examination may be \nperformed instead for diagnosis (grade D).\n•\t\tPainful\trectovaginal\tinduration/nodule,\tand\tvaginal\tnod-\nules in posterior vaginal fornix, may be due to deep endo-\nmetriosis (grade C).\n•\t\tClinicians\tmay\tregard\tpalpable\tovarian\tmass\tin\tpelvic\tex-\namination as an ovarian endometrioma (grade C).\n•\t\tClinicians\tmay\tconsider\tendometriosis\teven\tif\tthe\tpatients\t\nhave no abnormality in pelvic exam  (grade C).\nEndometriosis is diagnosed by past history, clinical examina-\ntion based on sign and symptom, radiologic findings, and \npathologic confirmation through laparoscopy [20,21]. Clini -\ncians can definitively diagnose as endometriosis when endo-\nmetrial glands and stromal tissue are found pathologically via \nlaparoscopy. In many cases, clinicians regard typical endome-\ntriosis lesion in abdominal cavity as proof of endometriosis. \nClinicians may prescribe pain relief medication for in invasive \nprocedures.\n3. Laparoscopy\n•\t\tHistologic\tproof\tof\tendometriosis\tthrough\tlaparoscopy\tis\t\nthe gold standard of endometriosis diagnosis. Although \nlaparoscopy without pathologic confirmation has limited \nvalue, the absence of histologic confirmation cannot ex -\nclude endometriosis (grade D).\n•\t\tKSE\t recommends \t biopsy \t and\t histologic \t confirmation \t\nwhen patient have endometrioma and/or deep endome-\ntriosis to exclude malignancy (grade D).\nAlthough there is an insufficient number of studies that \nsuggest laparoscopy without biopsy has compatible accuracy \n\nwww.ogscience.org 555\nHyejin Hwang, et al. Clinical guideline for endometriosis\nof diagnosis to histologic confirmation, clinicians may exclude \nendometriosis when the patient has no suspicious lesion on \ndiagnostic laparoscopy [22-24]. It is only possible laparoscopy \nis performed appropriately and pre-operative evaluation is ad-\nequate. Laparoscopic endometriosis diagnosis without biopsy \nhas limited value [25].\n4. Ultrasound\n•\t\tKSE\t recommends\t transvaginal\t or\t transrectal\t ultraso -\nnography to confirm or exclude ovarian endometriomas \n(grade A).\n•\t\tIn\t premenopausal\t women,\t ovarian\t endometrioma\t has\t\nultrasonographic findings, ground grass echogenicity, 1 to  \n4 compartments, absence of papillary structure, and \nblood flow (grade D).\n•\t\tTransvaginal\tor\ttransrectal\tultrasonography\tmay\tbe\thelp-\nful for patient with rectal endometriosis related signs \nand/or symptoms to confirm or exclude endometriosis \n(grade A).\nKSE does not recommend the general use of transvaginal \nsonography for the diagnosis of rectal endometriosis, because \ndiagnostic accuracy is low unless performed by a highly expe-\nrienced expert [24,26,27].\n5. Magnetic resonance imaging\n•\t\tClinicians\tshould\tdecide\ton\tfollow-up\tassessment\tthrough\t\nadditional imaging evaluation including magnetic reso -\nnance imaging (MRI), when deep endometriosis infiltrat-\ning ureter, bladder, or bowels is suspected in patients’ \nhistory and clinical examination (grade D).\n•\t\tIt\tis\tnot\tyet\tverified\tyet\tthat\tMRI\tis\tuseful\tfor\tdiagnosis\tof\t\nperitoneal endometriosis (grade D).\nClinicians should perform additional evaluation, such as cys-\ntoscope, colonoscopy, barium enema, rectal sonography, or \nMRI, for suspected deep endometriosis [20,25].\n6. Biomarkers \n•\t\tIt\tis\tnot\tyet\twell\tverified\tyet\tthe\tuse\tof\tbiomarker\tfrom\t\nendometrial tissue, menstrual bloods, and uterine fluids, \nor immunological biomarker such as CA125 from plasma, \nurine, or serum is helpful for the diagnosis of endometrio-\nsis (grade A).\nMany researchers have studied various biomarkers, but clini-\ncal application is still limited. If diagnostic value is revealed, \nclinicians may be able to correctly diagnose endometriosis less \ninvasive [28-30].\nInfertility\n•\t\tKSE\trecommends\tthe\tremoval\tof\tadhesions\tby\texcision\tor\t\nablation of endometriosis lesion to improve spontaneous \npregnancy rates for laparoscopically diagnosed minimal \nendometriosis (American Society for Reproductive Medi -\ncine [ASRM] stage 1, 2) for infertile women (grade A).\nAs published literatures, operative laparoscopy is better \nthan simple diagnostic laparoscopy for spontaneous preg -\nnancy rate, in minimal or mild case of endometriosis [31-33]. \nThere are only a few studies the compare the pregnancy rates \namong operation methods [34]. For minimal or mild endo -\nmetriosis, CO2 laser vaporization may improve pregnancy rate \nmore than monopolar electro-coagulation [31].\n•\t\tIn\tinfertile\twomen\twith\tsevere\tendometriosis\t(ASRM\tstage\t\n3, 4), operative laparoscopy shows higher spontaneous \npregnancy rate than expectant management (grade A).\nStill now, the gap between surgical and expectant manage-\nment is not well studied, but surgical methods, laparoscopic \nor laparotomy surgery demonstrate a superior pregnancy rate \nof, 45–69%, compared to expectant management [34]. How-\never, clinicians should pay attention to normal ovarian tissue \nconservation when doing operation.\n•\t\tKSE\trecommends\tovarian\tcystectomy,\tinstead\tof\tdrainage\t\nand/or coagulation, because it may improve spontaneous \npregnancy rate (grade A).\n•\t\tOvarian\tfunction\tmay\tdecline\tafter\tan\toperation\tfor\tovar-\nian endometrioma (grade D).\nThere is a study that claims cystectomy improves spontane-\nous pregnancy rate compared to drainage/coagulation of en-\ndometrioma (≥3–4 cm) [35]. Clinicians should discuss about \npossible decline in ovarian function with patient sufficiently. \nRepeated operation had little influence on pregnancy rate im-\nprovement [36].\n•\t\tWhen\tthe\tpatient\twants\tto\tconceive\tnaturally\tright\tafter\t\noperation, clinicians should not prescribe adjuvant hor -\n\nwww.ogscience.org556\nVol. 61, No. 5, 2018\nmonal treatment (grade A).\n•\t\tClinicians\t should\t not\t suppress\t ovarian\t function\t by\t hor-\nmonal treatment to improve fertility, in infertile women \nhaving endometriosis (grade A).\nAdjuvant medical treatment after surgery is for removing \nremnant endometriosis, and there is no evidence that states \nit raises pregnancy rates [36,37]. Ovarian suppression by oral \ncontraceptive, progestin, gonadotropin-releasing hormone \n(GnRH) agonist, or danazol is not helpful in enhancing fertil-\nity [38].\n•\t\tClinicians\t should\t try\t assisted\t reproductive\t technology \t\n(ART) to infertile women with endometriosis, when causes \nof infertility are the compromised tubal function and/or \nmale factor. It may be attempted, if patient has already \nfailed to other infertility management (grade D).\n•\t\tClinicians\t may\t consider\t controlled\t ovarian\t stimulation \t\nfollowed by intrauterine insemination in infertile women \nwith ASRM stage 1, 2 endometriosis women (grade C).\n•\t\tIn\tinfertile\twomen\twith\tsevere\tendometriosis\t(ASRM\tstage\t\n3, 4), in vitro fertilization-embryo transfer (IVF-ET) is an ef-\nfective alternatives, if the patient have trouble conceiving \nafter operation, or is of old age (grade C).\nAccording to blind studies, regarding minimal or mild endo-\nmetriosis women, controlled ovarian stimulation followed by \nintrauterine insemination showed 5 times higher pregnancy \nrate than observation. It is reported that intrauterine insemi -\nnation combined with controlled ovarian stimulation improves \npregnancy rate compared to IUI only method [31,34].\n•\t\tKSE\t recommends\t the\t use\t of\t GnRH\t agonists\t for\t 3–6\t\nmonths before ART to improve fertility in women with \ninfertility diagnosed with endometriosis (grade B).\nCochrane review reported a 4-fold increase of pregnancy \nrate in GnRH agonist treatment prior to ART. However it is not \nwell understood how this effect can be applied endometrio -\nsis, and the mechanism is not demonstrated convincingly [36].\n•\t\tIn\tinfertile\twomen\twith\tendometrioma\t(≥3\tcm),\tthere\tis\t\nlack of evidence to support whether cystectomy prior to \nART increase pregnancy rate (grade A).\nMany studies evaluated fertile influence of endometrioma \nexcision, but there are no united results. Clinicians should be \naware of the possibility of decrease in ovarian function by sur-\ngical resection.\n•\t\tKSE\tdoes\tnot\trecommend\tsupplying\tspecific\tnutrients\tor\t\napplying alternative medicine to infertile women with en-\ndometriosis. However some women may feel that these \ntreatments would be helpful (grade D).\n•\t\tIt\tis\tpossible\tthe\tthere\tis\tan\tincreased\tincidence\tof\tsponta-\nneous abortion, preterm delivery, small for gestational age \n(SGA), or placenta previa, when the mother has endome-\ntriosis in pregnancy (grade B).\nEndometriosis may increase the pregnancy related compli -\ncation. It is reported to show 1.37 times higher in number \nof preterm delivery, 1.13 times placenta previa, 1.76 times in \npostpartum bleeding or placenta related complication, and \n1.47 times for cesarean delivery ratio. SGA or fetal death in \nuterus, however, are not increased [37].\nMedical treatment of endometriosis-\nassociated pain\n•\t\tThere\t is\t no\t evidence\t that\t one\t medication\t has\t superior\t\nover any other medications, for endometriosis-associated \npain treatment (grade A).\nClinicians should personalize the medication depending on \nside effects, compliance, and costs. Most randomized con -\ntrolled trials about treatment of endometriosis-associated pain \nare aimed at surgically diagnosed endometriosis. Many stud-\nies mention unclearly whether operative or only diagnostic \nlaparoscopy was done. In addition, researchers did not inves-\ntigate the efficacy of long-term treatment (≥6 months). There \nis insufficient evidence to supports any medication is better \nthan others.\n1. Empirical treatment\nImaging modalities are increasing in accuracy for endome -\ntrioma and deep infiltrative endometriosis (DIE), though \nlaparoscopy is an important method to diagnose endome -\ntriosis. Therefore, when endometriosis is suspected by clinical \nevidence or radiologic diagnosis, clinicians can begin medical \ntreatment without operative confirmation [39-41].\n \n2. Combined oral contraceptives\n•\t\tClinicians\tmay\tprescribe\tcombined\toral\tcontraceptives\tfor\t\n\nwww.ogscience.org 557\nHyejin Hwang, et al. Clinical guideline for endometriosis\nendometriosis related pain control (grade B).\n•\t\tContinuous\t use\t of\t combined\t oral\t contraceptives\t has\t\nadvantages for pain relief compare to cyclic medication \n(grade C).\nThere are rare randomized controlled trials which proved \nthe effects of oral contraceptive for endometriosis-associated \npain. In addition, it is not verified that a certain oral contra -\nceptive is better than others [42]. However, most observa -\ntional studies and guidelines recommend oral contraceptives \nas first line treatment for endometriosis-associated pain. KSE \nrecommends continuous usage, because 20–40% of cyclic \nusers experience pain during withdrawal bleeding, and 50% \nof women who have pain with cyclic use get better with \ncontinuous use. Moreover, both groups show similar safety \nand recurrence rates. Occasionally, women with continuous \nuse may experience unexpected vaginal bleeding, so some \nclinicians recommend continuous use of 4–7 cycles with 4–7 \ndays of withdrawal period; a so called pre-planned extended \nregimen. Individualization is most important for enhancing \ncompliance [43,44].\n3. Progestins \n•\t\tKSE\t recommends\t progestin,\t such\t as\tmedroxyprogester-\none acetate (MPA), dienogest, or norethisterone acetate \nfor endometriosis-associated pain (grade A).\n•\t\tClinicians\t may\t use\t levonorgestrel\t intrauterine\t system \t\n(LNG-IUS) for endometriosis-associated pain (grade B).\nClinicians have tried various types of progestins, those that \nare commonly used include norethindrone acetate (NETA), di-\nenogest, and MPA. Patients may experience vaginal bleeding, \nweight gain, headache, mood change, and decreased libido. \nClinicians should consider bone density loss for long-term use \nof progestin. Direct comparative study dealing with specific \nmedication is superior to others in aspect of efficacy or side \neffect is rare [45]. Clinicians may prescribe progestins in con-\nsideration of side effects, costs, and compliance. For example, \nNETA and dienogest are both 19-nortestosterone derivatives, \n, but dienogest has an anti-androgenic effect NETA (it is par-\ntially metabolized as estrogen, so theoretically it may prevent \nof loss of bone density) is not available domestically. Dieno -\ngest has advantages for compliance due to few side effects, \nbut the effect of bone density has not been proved yet. \nClinicians can prescribe MPA for both oral and intramuscular \nroute, and subcutaneous formulation was developed recently. \nMPA has similar efficacy as GnRH agonist and decreases bone \ndensity temporarily. Although studies show recovery bone \ndensity after cessation of the medication, clinicians should be \ncautious on the long-term (≥2 years), and the use is not rec -\nommended in adolescents. Small scale studies reported that \nprogestin has a similar pain relief effect as GnRH agonist, so \nclinicians may use progestin on patients with side effects from \nother medications or low compliance [40,43].\n \n4. GnRH agonist\n•\t\tKSE\trecommends\tGnRH\tagonist\tfor\ttreatment\tof\tendo-\nmetriosis related pain (grade A).\n•\t\tClinicians\tshould\tprescribe\tadd\tback\ttherapy\tfor\tminimiz-\ning disadvantages of low estrogen symptom (grade A).\n•\t\tVarious\t medications,\t such \t as \t progestin,\t estrogen, \t\nestrogen+progestin, tibolone, etc. may use as add-back \ntherapy. More studies are needed regarding which medi-\ncation is most appropriate (grade C).\nThe effects of GnRH agonist for endometriosis related pain \nhave been studied extensively. GnRH agonists are superior to \nplacebo, but not to combined oral contraceptives. Clinicians \nshould prescribe add-back for low estrogenic symptom and \nloss of bone density. Various medications may be used as add \nback, and no specific medication is better than others. Add-\nback treatment do not reduce effect of pain control. Low \nestrogen symptom is the most concerning matter, yet the du-\nration of treatment is not identified. Most studies recommend \nless than six months only for women over 18 years of age \n[40,43,44].\n5. Other medications\n•\t\tDanazol,\tand\tgestrinone\tare\teffective\tfor\tendometriosis\t\nrelated pain, but clinicians should be aware of the side ef-\nfects (grade C).\n•\t\tGnRH\tantagonists\tare\tnot\tappropriate\tfor\tcommon\tuse\t\n(grade C).\n•\t\tClinicians\tmay\tconsider\taromatase\tinhibitor\tmerging\twith\t\nother medication; such as Combined oral contraceptive \n(COC), progestin, and GnRH agonist, when usual therapy \nis not satisfactory (grade B).\nDanazol was the first medication approved by Food and \nDrug Administration (FDA), for endometriosis. It suppresses \novulation with powerful anti-estrogen effect and androgenic \neffect. However, clinicians prescribe restrictively nowadays \n\nwww.ogscience.org558\nVol. 61, No. 5, 2018\nbecause of its side effects such as vasomotor symptoms, liver \nfunction abnormality, and dyslipidemia. GnRH antagonist \nhas theoretical possibility, but only a few practical usages \nwere reported. Aromatase inhibitor delayed recurrence with \nanastrozole-combined therapy compared to goserelin in sole. \nA literature reported combined treatment letrozole 2.5 mg \nand NETA 2.5 mg is effective for patients who are resistant \nto other endometriosis medication. If other medications are \nineffective, aromatase inhibitor combined to other medication \nmay be used [43,44].\nSurgical treatment of endometriosis\n1. Targets for surgical treatment of endometriosis\n•\t\tAsymptomatic\tpatients\twhose\tendometriosis\twas\tinciden-\ntally discovered during operation, do not need medical or \nsurgical treatment (grade D).\n•\t\tSurgical\tmanagement\tof\tendometriosis\tfor\tendometriosis-\nrelated pain may be done after failure of medical treat -\nment (grade D).\nEndometriosis patients who have pelvic pain or ovarian en-\ndometrioma need surgical management. Eligible candidates \nfor surgical management are limited to patients who do not \nrespond to medical treatment or are contraindicated for it, \nor have acute adnexal diseases such as torsion or rupture, or \ndeep infiltrated endometriosis invading to bowel, bladder, \nureter, or pelvic nerve [46,47].\n2. Evaluation before operation\n•\t\tDecision\t for\t surgical\t management\t of\t endometriosis \t\nshould be based on clinical evaluation, imaging modality, \nand medical treatment response. Diagnostic laparoscopy \nshould be restricted (grade D).\n•\t\tImaging\tevaluation\tshould\t be\t based\ton\t symptoms\tand\t\nphysical examination (grade D).\n•\t\tDiagnostic\tvalue\tof\tpreoperative\tserum\tCA125\tis\tlimited.\t\nTherefore, usual examination of serum CA125 is not rec-\nommended before operation. But, it may be done as a \npart of evaluation for undiagnosed adnexal mass (grade D).\nPelvic ultrasonography, especially transvaginal sonography, \nis recommended for suspicious adnexal mass. Transrectal so-\nnography, colonoscopy, barium enema, and MRI are useful \nfor detecting rectovaginal septum infiltrative endometriosis. \nWhen patients have regular bladder symptoms, such as he -\nmaturia, cystoscopy is helpful [46]. Clinicians should discuss \nthe risk of surgical management with the patient, and get \ninformed consent.\n3. Surgical approach \n•\t\tClinicians\tshould\tnot\t prescribe\t hormonal\t treatment\tfor\t\nendometriosis pain control before surgery (grade A).\n•\t\tAdjunctive\thormonal\ttherapy\tafter\tsurgery\tis\tdivided\tinto\t\nshort-term (<6 months) and long-term (>6 months), and \nthe latter is intended for secondary prevention (grade D).\n•\t\tClinicians\tare\trecommended\tnot\tto\tprescribe\tadjunctive\t\nshort-term hormonal therapy for endometriosis associated \npain after surgery, because it does not add to the out -\ncome of surgery (grade A).\n•\t\tThe\t selection\t of\t adjunctive\t treatment\t for\t prevention\t of\t\nrecurrence and pain depends on patient preference, cost, \nefficacy and side effects (grade D).\nAlthough clinicians prescribe GnRH agonists to reduce \ninflammation, blood flow, and adhesions in endometriosis, \npreoperative hormonal treatment did not reduce both en -\ndometriosis related pain and recurrence [40]. Therefore, KSE \ndoes not recommend preoperative hormone treatment for \nendometriosis related pain and/or prohibiting recurrence.\nAdjuvant hormonal treatment has two purposes. In the \nshort-term, it makes additional effect on pain relief effects of \nsurgical treatment. Long-term treatments (≥6 months) may \nreduce recurrence [48].\nStudies suggest that patients with post-operative hormonal \ntherapy have lower degree of pain after 12 months. However \nin terms of pain recurrence, there is no significant difference \nwith one year risk ratio of 0.76 (95% confidence interval [CI], \n0.52–1.1), and 2 year risk ratio of 0.70 (95% CI, 0.47–1.03) [49].\n \n4. Results of surgical treatment\n•\t\tSurgical\tremoval\tof\tlaparoscopically\tdiagnosed\tendome-\ntriosis can be helpful for pain relief (grade A).\n•\t\tKSE\trecommends\tsurgical\tresection\tof\tovarian\tendome-\ntrioma, because it is more efficient to prevent pain recur-\nrence than drainage or coagulation (grade A).\n•\t\tIf\tthe\tpatient\thas\tfinished\tchild\tbearing,\tand\tnot\trespon-\nsive to conservative management, clinicians may operate \ntotal hysterectomy and both salpingo-oophorectomy, and \nsurgical removal of endometriosis. However, clinicians \n\nwww.ogscience.org 559\nHyejin Hwang, et al. Clinical guideline for endometriosis\nshould explain that total hysterectomy is not essential for \nthe treatment of endometriosis (grade D).\n•\t\tKSE\trecommends\tcontinuously\tprescribing\tcombined\tes-\ntrogen/progestogen or tibolone (grade C).\n•\t\tLaparoscopy\tis\tpreferred\tto\tlaparotomy\tfor\tsurgical\ttreat-\nment of endometriosis (grade C).\n•\t\tClinicians\tmay\tuse\tanti\tadhesion\tagents\tduring\tendome-\ntriosis-related operation (grade B).\nWhen endometriosis lesion is resected surgically, 80% \nof patients are relieved of pain after operative laparoscopy \ncompared to 32% of patients after diagnostic laparoscopy \n[35]. Cochrane review reported that the surgical resection \nof endometriosis reduces the endometriosis-related pain by \n6.5 times less after 6 months and by 10 times lower after 12 \nmonths. Surgical resection of endometrioma is more effective \nthan drainage or coagulation for dysmenorrhea, dyspareunia, \nor chronic pelvic pain [50]. It lowers the recurrence of endo -\nmetriosis, and additional operation owing to recurrence, and \nenhances ovarian follicle response to gonadotropin. However, \nclinicians should be aware that cystectomy may damage the \novarian tissue and reduce the function of the ovary function. \nDrainage is not recommended because 80–100% of endo -\nmetriosis will recur within 6 months. Total hysterectomy and \nboth adnexectomy regress remnant endometriosis lesion and \nreduce recurrence rate of endometriosis-related pain as much \nas 6 times and as much as 8.1 times at re-operation [41]. Cli-\nnicians should consider hormone replacement therapy after \nboth adnexectomy. KSE recommends estrogen-progesterone-\ncombined therapy, because recurrence rate is lower than \nestrogen-only therapy or no adjuvant therapy. \nAnti-adhesion agents are beneficial to patients who have no \nendometriosis. Clinicians can use oxidized regenerated cellu-\nlose on operative laparoscopy of endometriosis, but icodextrin \nhas no proven effect [40].\n•\t\t \tWhen\tpatients\thave\tre\toperation\tfor\trecurrent\tendometri-\nosis, endometriosis is recurred in 20–40% of cases, similar \nto the recurrence rate after the first operation (grade A).\n•\t\tClinicians\tshould\tcarefully\tconsider\trepeating\tthe\topera-\ntion, for the degree of pain relief after operation is signifi-\ncantly decreased when operation is repeated (grade C).\n•\t\tAlthough\t there\t is\t insufficient\t evidence,\t follicular\t phase\t\nmay be beneficial for endometriosis operation (grade D).\nAbout 83% of patients who had surgery still had endome-\ntriosis-related pain. After repeated operation, only 53% of \npatients experienced pain relief. Therefore, clinicians are ad -\nvised to carefully consider repeating the operation [49].\nFollicular phase is best for operating. During the luteal \nphase, clinicians may mistake corpus luteal cyst for endome-\ntrial cyst. In addition, endometrial tissue can be re-implanted \nby the following menstruation. \n5. Deep infiltrative endometriosis\nDIE operation should be based on a multidirectional approach \nand professional experience. Clinicians should give various \nand professional treatment, and also consider surgical exci -\nsion of extragenital endometriosis for symptom relief.\n6. Ovarian endometrioma\n•\t\tClinicians\t should\t consider\t the\t patient’ s\tfuture\tplans\t for\t\nchildren when deciding on the therapeutic range of ovar-\nian endometrioma (grade D).\n•\t\tOvarian\tendometrioma\tmay\timplicate\tthe\twidespread\ten-\ndometriosis (grade D).\n•\t\tIn\twomen\twith\tovarian\tendometrioma,\tKSE\trecommends\t\ncystectomy compared to drainage or CO2 laser vaporiza-\ntion. Ovarian cystectomy reduces pain and recurrence, \nand allows histological diagnosis (grade A).\n•\t\tClinicians\tshould\tremove\tovarian\tendometrioma\t(≥3\tcm)\t\nin women with pelvic pain (grade A).\n•\t\tClinicians\tshould\tprescribe\tpost-operative\thormone\tthera-\npy for women who do not plan on pregnancy (grade A).\n•\t\tClinicians\tshould\tprescribe\tLNG-IUS,\tCOC,\tor\tprogestin\tat\t\nleast 18–24 months after operation (grade A).\nPatients who received cystectomy have lower recurrence \nrate of dysmenorrhea, dyspareunia, and pelvic pain, than \nthose who received drainage or coagulation for endometrial \ncyst. After the operation, patients who took COC during 6–24 \nmonths, experienced reduced dysmenorrhea, but no change \nin dyspareunia and pelvic pain. Combined oral contracep -\ntive treatment within 6 months after operation also did not \nreduce endometriosis-related pain [18,36]. Both continuous \nand cyclic use of hormonal therapies is similarly effective, \ntherefore the choice of medication should depend on pa -\ntient preference, cost, and side effects. The more/longer the \npatient carried on therapy, the less amount of pain recurred. \nWomen who were taking combined oral contraceptives \nshowed lower rate of ultrasonographically-diagnosed ovarian \n\nwww.ogscience.org560\nVol. 61, No. 5, 2018\nendometrioma. \nStudies have reported that the use of LNG-IUS lowered dys-\nmenorrhea in women with previous experience of endome -\ntriosis operation and severe dysmenorrhea. The use of GnRH \nagonist, danazol, MPA, and pentoxifylline after operation \nshows no additional advantage to reduce pain recurrence. \n7. Additional treatment\n•\t\tKSE\tdoes\tnot\trecommend\tlaparoscopic\tuterosacral\tnerve\t\nablation (LUNA) as an additional step to conservative sur-\ngery for endometriosis associated pain (grade A).\n•\t\tClinicians\t can\t perform\t presacral\t neurectomy\t (PSN)\t for\t\nendometriosis associated midline pain as additional pro -\ncedure to conservative surgery. It is effective, but risky and \nrequires high degree skill (grade A).\nAlthough it increases the risk of uterine prolapse and ureter \ndamage, additional LUNA made no difference in symptom \nimprovement after 6 months and 12 months, compared to \nestablished operations. PSN is effective for midline pain, but \nmay have other complications such as bleeding, constipation, \nurinary retention, urgency, or insensibility to the first stage of \nlabor, therefore requires a highly skilled expert to perform the \nsurgery [40].\nRecurred endometriosis\n•\t\tClinicians\tshould\tavoid\tsecond\tline\tsurgery\tin\twomen\twho\t\nwant to conceive when endometriosis is recurred after the \nfirst surgery (grade B).\n•\t\tClinicians\tmay\ttry\tempirical\thormonal\ttreatment\tfor\trecur-\nrent endometriosis-related pain between in vitro fertiliza-\ntion (IVF) procedure cycles (grade D).\nThere is a study about the effect of second line surgery for \nrecurrent endometriosis. Out of 313 patients who attempt \nto conceive, and 81 patients (26%; 95% CI, 21–31%) were \npregnant. There is no significant difference between laparos-\ncopy (27%) and laparotomy (25%) [51,52]. In conclusion, \npregnancy rates after IVF in recurrent endometriosis women is \nnot inferior to that after second line surgery. Pregnancy after \nsecond line surgery is decreased compared to the first line \nsurgery. Muzii et al. [53] reported that second line surgery to \nrecurrent ovarian endometrioma may more severely damage \novarian tissue more, and decrease ovarian reserve compared \nto first line surgery. \nTherefore, if possible, clinicians should avoid second line \nsurgery for recurrent endometriosis in women who plan on \ngetting pregnant. Clinicians may try empirical hormonal treat-\nment for recurrent endometriosis-related pain between IVF \nprocedure cycles.\nAsymptomatic endometriosis\n•\t\tIt\tis\tunnecessary\tto\tremove\tincidentally-diagnosed\tperito-\nneal, ovarian, deep endometriosis (grade D).\nAsymptomatic endometriosis is defined as incidentally-di -\nagnosed pelvic, ovarian, or deep endometriosis without pain, \nor infertility. Accurate incidence cannot be found, but 3–45% \nwomen who received laparoscopic tubal ligation have endo-\nmetriosis [54].\nThere is no report that supports treatment of incidentally-\ndiagnosed asymptomatic endometriosis. When research -\ners track the patient with asymptomatic endometriosis, the \npatient rarely experiences any symptoms [55,56]. Therefore, \nsurgical treatment of endometriosis is not recommended. \nMeanwhile, some researches recommend excision of en -\ndometrioma, for a type of ovarian cancer may be related to \nendometriosis. However, the risk of ovarian cancer is very low \nand a definite relation has not been verified [57,58]. There -\nfore, clinicians do not have to surgically remove asymptomatic \nendometrioma [41].\nEndometriosis of adolescents\n•\t\tGenerally,\t treatment\t of\t adolescents’\t endometriosis\t is\t\nbased remedy of adults (grade D).\n•\t\tClinicians\tshould\tbe\taware\tof\tloss\tof\tbone\tdensity,\twhen\t\nprescribing GnRH agonist to adolescents (grade D).\nThe guideline for adolescent endometriosis is based on \nstudies for adults because the studies aimed at adolescents \nare extremely limited. \nClinicians may start medical treatment for suspicious en -\ndometriosis of adolescents and should take into account the \npatient’s age and side effects. Nonsteroidal anti-inflammatory \ndrugs (NSAIDs) are the first line treatment for dysmenor -\nrhea. COC are the alternatives for resistant to NSAIDs. Many \n\nwww.ogscience.org 561\nHyejin Hwang, et al. Clinical guideline for endometriosis\nluteal hormones reduce endometriosis-related pain, so it \nmay substitute COC. However, there is risk of bone density \nloss. Clinicians may prescribe GnRH agonist for pain relief \nwhen patients are reluctant to surgery [59-61]. KSE does not \nrecommend prescribe it for patients younger than 16 years \nold, because of possibility of bone density loss. Usually GnRH \nagonists are used on patients over 18 years of age. Clinicians \nshould prescribe add back, and check the intake of calcium \nand vitamin D, as well as bone density [61].\nClinicians should be more careful when deciding on surgery \nwhen it comes to adolescent patients. Experts with copious \nexperience on adolescent endometriosis should perform the \nsurgery, because endometriosis of adolescents takes different \naspects [60-63]. Studies on the effects of surgical treatment of \nadolescents are insufficient, though the treatment may effec-\ntive reduce pain. Clinicians should consider long-term medical \ntreatment after operation for recurrence prevention. There is \nno consensus that adjuvant medical treatments are necessary \nfor all adolescent patients nor that long-term problems such \nas recurrence or infertility may be prevented [64]. \nEndometriosis in menopausal women\n•\t\tEndometriosis\t may\texist\tafter\tnatural\t or\tsurgical\t meno-\npause, but symptoms usually disappear (grade D).\nClinicians should not hesitate to prescribe hormone replace-\nment therapy in symptomatic menopausal women with endo-\nmetriosis [65].\n•\t\tKSE\trecommends\tthe\tadministration\tof\tcontinuous\tcom-\nbined estrogen-progestin therapy or tibolone (grade C).\n Endometriosis is able to recur after hormone therapy if the \nprevious operation did not sufficiently remove endometriosis. \nTherefore, clinicians should closely watch the patient’s symp-\ntoms [66,67]. \nEndometriosis and ovarian cancer\n•\t\tClinicians\tshould\tconfirm\tpathologic\tdiagnosis\tafter\top-\nerative treatment.\n•\t\tKSE\tdoes\tnot\trecommend\tadditional\tevaluation\tfor\tovar-\nian cancer in women with endometriosis, because the \nincidence of ovarian cancer is very low (grade A).\nAs meta-analysis of patient-control studies, women with \nendometriosis history have significantly higher risk of clear \ncell (odds ratio [OR], 3.05), low-grade serous (OR, 2.11), and \nendometrioid invasive ovarian cancer (OR, 2.04) [57]. Still, cli-\nnicians should recognize that the overall risk of ovarian cancer \nis extremely low. \nConclusion\nThis guideline is the first structured and evidence-based \nreview for Korean endometriosis patients. There are some \nrecommendations which are based on experts’ opinions only, \nand actually many studies and clinical experiences are still in \nprogress. Therefore, we expect that many answers will be \nprovided with get high quality evidences in later guidelines. \nAcknowledgements\nThe authors are grateful to Jee Yune Park and to Jong-Gu \nShin for their proofreading on the manuscript.\nThis guideline is based on The Korean Society of Endome -\ntriosis (KSE) clinical guideline 2017. KSE members agreed to \nsubmit this guideline to Obstet Gynecol Sci as a review article.\nConflict of interest\nNo potential conflict of interest relevant to this article was re-\nported.\nReferences\n  1. Gruppo italiano per lo studio dell'endometriosi. 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Maturitas 2010;67:94-7.","source_license":"CC0","license_restricted":false}