{"paper_id":"ac16ba27-2e44-4901-825c-ebc216623095","body_text":"1\nInternational Journal of Health Science ISSN 2764-0159 DOI https://doi.org/10.22533/at.ed.1595152518034\nInternational \nJournal of\nHealth \nScience\nv. 5, n. 15, 2025\nAll content in this magazine is \nlicensed under a Creative Com -\nmons Attribution License. Attri -\nbution-Non-Commercial-Non -\nDerivatives 4.0 International (CC \nBY-NC-ND 4.0).\nAcceptance date: 18/03/2025\nPHARMACOLOGICAL \nAND SURGICAL \nAPPROACHES TO THE \nMANAGEMENT OF \nENDOMETRIOSIS\nRyan Rafael Barros de Macedo\nMedical student at the Apparecido dos \nSantos Central Plateau University Center \n(UNICEPLAC)\nhttps://orcid.org/0009-0003-3917-581X\nJosé Carlos Gomes de Sousa\nBachelor of Nursing at the University of \nInternational Integration of Afro-Brazilian \nLusophony (UNILAB)\nAna Clara Oliveira Neves\nStudent - Medicine at Faculdade Atenas - \nPorto Seguro\nKlinger Gomes dos Santos Almeida\nBachelor - Medicine - Amazonas State \nUniversity\nVictoria Rodrigues de Sousa dos Santos\nStudent - Nursing at the University of Brasília \n(UnB)\nJoão Paulo Lopes Araújo\nBachelor - Medicine at the Federal University \nof Piauí (UFPI)\nMatheus Fernandes Ribeiro Costa\nStudent - Medicine at the Federal University \nof Triângulo Mineiro (UFTM)\nJoanderson Carvalho Costa\nStudent - Nursing at the Teresina College of \nTechnology - CET\nLigia Maria Senigalia Bacca\n\n \n2\nInternational Journal of Health Science ISSN 2764-0159 DOI https://doi.org/10.22533/at.ed.1595152518034\nStudent - Medicine at the Campo Real \nUniversity Center\nMarina Gabriela Teixeira Costa\nStudent - Medicine at the Central University \nof Paraguay (UCP)\nhttps://orcid.org/0009-0009-3265-9620\nGuilherme Thomas Ferreira Lucena\nBachelor - Medicine - Estácio de Juazeiro do \nNorte Medical School - CE (FMJ)\nAmanda Bello Zeidan\nStudent - Medicine at the University for the \nDevelopment of the State and the Pantanal \nRegion (Uniderp)\nAbstract: Endometriosis is a gynaecological \ndisease characterized by the presence of en -\ndometrial tissue outside the uterus, causing \nchronic pain and infertility in many women. \nThe treatment of endometriosis involves \npharmacological approaches, such as the use \nof estroprogestins and GnRH agonists, and \nsurgical interventions to excise the lesions. \nThe choice of treatment depends on the se -\nverity of the symptoms, the location of the \nlesions and the patient’s individual response. \nThe management of endometriosis remains a \nchallenge due to resistance to treatment, the \nvariability of the lesions and post-treatment \nrecurrences. This paper reviews the latest tre-\natments, highlighting the advances and diffi -\nculties in managing the disease, with a focus \non personalizing therapy to meet the needs of \neach patient.\nKeywords: Endometriosis, Pharmacological \ntreatment, Surgical excision, Personalized \ntherapy, Pelvic pain, Infertility, Pathophysio -\nlogy.\nINTRODUCTION\nEndometriosis is a complex gynecological \ncondition that affects a significant proportion \nof women of reproductive age, with an esti -\nmated prevalence of between 6% and 10% of \nthe female population. It is characterized by \nthe presence of endometrial tissue outside the \nuterine cavity, usually in the peritoneum, whi-\nch can also affect other organs. The etiology \nof the disease is not fully understood, but the \nretrograde menstruation theory is widely ac -\ncepted, suggesting that endometrial cells flow \nback into the pelvic cavity during menstrua -\ntion, settling in ectopic locations. However, in \nrecent years, the genetic-epigenetic (GE) the -\nory has gained prominence, proposing that en-\ndometriosis is triggered by a series of genetic \nand epigenetic alterations that allow pluripo -\ntent cells to differentiate into endometrial tis-\nsue outside the uterus. These alterations partly \n\n \n3\nInternational Journal of Health Science ISSN 2764-0159 DOI https://doi.org/10.22533/at.ed.1595152518034\nexplain the variability of the disease, such as \nthe difference in responses to hormonal tre -\natments and pain patterns between patients. \nThe evolution of endometriotic lesions is also \nassociated with environmental factors, inclu -\nding retrograde menstruation and the perito-\nneal microbiome, which suggests a complex \ninteraction between genetics, epigenetics and \nthe environment in the development of the di-\nsease. (AMRO et al., 2022)\nThe symptoms of endometriosis are varied, \nincluding chronic pelvic pain, dyspareunia, \nmenorrhagia and, in many cases, infertility. \nAlthough laparoscopy is the standard method \nfor diagnosis, imaging tests such as ultrasou -\nnd and MRI play a key role in the pre-surgical \nassessment of lesions. Classifying the disease \ninto minimal, mild, moderate and severe sta -\nges helps guide treatment, although the severi-\nty of the lesions does not always correlate with \nthe intensity of the symptoms. In addition, \nrecent studies highlight that the immune res -\nponse plays a crucial role in the viability and \ngrowth of endometriotic tissue, with chronic \ninflammation contributing to prolonged pain \nand the formation of fibrosis around the le -\nsions. (PAŠALIĆ; TAMBUW ALA; HROMIĆ-\n-JAHJEFENDIĆ, 2023) Recognizing these va-\nriabilities has enabled advances in therapeutic \napproaches, taking into account the specific \ncharacteristics of each patient, such as resis -\ntance to certain hormones or the presence of \nremote neuroinflammation, which alters the \nappropriate treatment.\nThe treatment of endometriosis is multifa-\nceted, involving pharmacological and surgi -\ncal options. Hormonal therapies, such as oral \ncontraceptives, progestogens and GnRH ana-\nlogues, are often used to control the growth \nof endometrial tissue and relieve symptoms. \nHowever, the effectiveness of these therapies \ncan be variable, with some patients showing \nresistance to the hormones. The surgical \napproach, on the other hand, focuses on exci-\nsing the endometriotic lesions, with laparos -\ncopy being the technique of choice. In cases of \ncystic ovarian endometriosis and deep endo -\nmetriosis, conservative excision is generally \npreferred, with removal of the lesions without \nthe need for safety margins around the fibrous \nareas. In addition, superficial removal of cys -\ntic ovarian lesions is often sufficient to achieve \nsymptom relief. A more detailed understan -\nding of the pathophysiology of endometriosis, \nincluding the characteristics of the lesions and \nthe associated risk factors, has allowed treat -\nment to be personalized, promoting a more \neffective and less invasive approach. (KONIN-\nCKX et al., 2021)\nThe search for an early diagnosis, combi -\nned with more targeted treatments, represents \na significant advance in the management of \nendometriosis, offering better prospects for \ndisease control and quality of life for affected \nwomen. (PAŠALIĆ; TAMBUW ALA; HRO -\nMIĆ-JAHJEFENDIĆ, 2023)\nMETHODOLOGY\nThe methodology adopted for the litera -\nture review aimed to synthesize the latest in -\nformation on pharmacological and surgical \napproaches to the management of endome -\ntriosis. To do this, a search was carried out in \nthe PubMed database, using the descriptors \n‘Endometriosis’ and ‘Treatment’, in order \nto select relevant articles published in the last \nfive years. The articles included were those \nthat specifically addressed the treatment of \nendometriosis, considering both pharmaco -\nlogical and surgical approaches. Studies that \nwere not available in the PubMed database or \nthat did not meet the inclusion criteria, such \nas those that did not deal directly with the -\nrapeutic interventions, were excluded. In ad -\ndition, duplicate articles or those with signi -\nficant methodological flaws were disregarded. \nThe selection was carried out carefully, with \nthe aim of ensuring that the studies were cur-\n\n \n4\nInternational Journal of Health Science ISSN 2764-0159 DOI https://doi.org/10.22533/at.ed.1595152518034\nrent, relevant and of high quality, ensuring the \nreproducibility and transparency of the pro -\ncess. Based on this analysis, the information \nextracted was organized in such a way as to \nprovide an up-to-date overview of the diffe -\nrent treatment options for endometriosis, hi -\nghlighting the most recent advances and chal-\nlenges.\nRESULTS AND DISCUSSION\nEndometriosis is a multifaceted clinical \ncondition that requires a personalized thera -\npeutic approach, given the variability of the \nlesions and the symptoms presented by pa -\ntients. Pharmacological treatment remains a \ncentral option, with the widespread use of es-\ntroprogestins, progestins and GnRH agonists \nor antagonists, whose therapeutic effects are \nwell documented. However, the effectiveness \nof these treatments is not uniform, with a sa -\ntisfactory response in approximately 70% of \npatients, but minimal or non-existent relief in \n10% to 20% of cases. This variability in res -\nponse can be attributed to the heterogeneity of \nendometriotic lesions, which makes it difficult \nto predict the effectiveness of treatments and \nrequires therapeutic adjustments over time. \nPeriodic evaluation of the treatment using ul-\ntrasound every 6 months has been suggested \nto monitor the evolution of the lesions, since \nthey can continue to grow even with conti -\nnued use of the medication. (KONINCKX et \nal., 2021)\nIn addition, the pathophysiology of endo -\nmetriosis, characterized by high estrogenic \nactivity in the lesions, justifies the medical \napproach aimed at reducing circulating estro-\ngen and progesterone levels, particularly in \nperitoneal lesions, where these hormones are \npresent in significantly higher concentrations \nthan in plasma. However, the effectiveness of \nthis strategy continues to be debated, since \nsome lesions can develop resistance to pro -\ngesterone and show aromatase activity, which \nmakes treatment more complex. This resis -\ntance may be related to specific clonal cha -\nracteristics of the lesions, which show distinct \nbiochemical behaviors, making it difficult to \nchoose a single, effective treatment for all pa -\ntients. (AMRO et al., 2022; KONINCKX et al., \n2021)\nSurgically, excision of endometriosis le -\nsions remains the preferred approach in many \ncases, with the aim of removing as much en -\ndometriotic tissue as possible with minimal \ndamage to adjacent tissues. Surgical excision \nis especially recommended for deep lesions \nand in critical locations, such as the intestine \nand ureters, where lesions can cause signifi -\ncant complications, such as intestinal obs -\ntruction and ureteral stenosis. The strategy \nof conservative excision is discussed, based \non the theory that fibrosis can be considered \npart of the body, which allows for a less inva -\nsive approach, with short resections and wi -\nthout the need for wide resections, as occurs \nin some more aggressive procedures. The use \nof techniques such as laser vaporization for \nsuperficial lesions and chemical destruction, \nsuch as alcoholization, for larger lesions, have \nbeen suggested as therapeutic options that \nminimize the risk of recurrence and post-ope-\nrative adhesions, a frequent problem in more \ninvasive interventions. (AMRO et al., 2022)\nHowever, it is important to note that the \nsurgical approach is not without its challen -\nges. Recurrences are seen, especially in areas \nsuch as the vaginal dome, where wide excision \nis considered the best strategy to avoid new le-\nsions. Additionally, the role of neural invasion \nin pelvic pain associated with endometriosis \nis still uncertain, and how this affects the sur-\ngical approach and pain resolution remains a \nfield. (AMRO et al., 2022)\n\n \n5\nInternational Journal of Health Science ISSN 2764-0159 DOI https://doi.org/10.22533/at.ed.1595152518034\nCONCLUSION\nIn short, the review carried out shows that \nthe management of endometriosis requires \nan individualized therapeutic approach, \ngiven the complexity and variability of \nthe clinical manifestations of the disease. \nPharmacological treatments, which include \nthe use of estroprogestins, progestins and \nGnRH agonists, have shown significant efficacy \nin a considerable proportion of patients, \nalthough resistance to these hormones and \nthe heterogeneity of the lesions represent \nmajor challenges. At the same time, surgical \ninterventions, especially lesion excision, \nremain essential, especially in cases of deep \nendometriosis and in critical locations, despite \nthe risk of recurrence and the complications \ninherent in invasive procedures.\nFaced with this scenario, personalizing \ntreatment has emerged as a central element for \ntherapeutic success, requiring the integration \nof clinical, imaging and, where possible, \nmolecular data to guide the choice between \npharmacological and surgical approaches. \nImproved diagnostic methods and continuous \nresearch into new therapeutic strategies \nare essential to optimize the management \nof the disease, minimizing complications \nand improving the quality of life of affected \nwomen.\nTherefore, the treatment of endometriosis \nmust be conceived in a dynamic and adaptive \nway, respecting the particularities of each \npatient and the challenges inherent in the \nevolution of the disease.\nREFERENCES\nAMRO, B. et al. New Understanding of Diagnosis, Treatment and Prevention of Endometriosis. International Journal of \nEnvironmental Research and Public Health, v. 19, n. 11, p. 6725, 31 maio 2022. \nKONINCKX, P . R. et al. Pathogenesis Based Diagnosis and Treatment of Endometriosis. Frontiers in Endocrinology, v. 12, p. \n745548, 25 nov. 2021. \nPAŠALIĆ, E.; TAMBUW ALA, M. M.; HROMIĆ-JAHJEFENDIĆ, A. Endometriosis: Classification, pathophysiology, and \ntreatment options. Pathology - Research and Practice, v. 251, p. 154847, nov. 2023.","source_license":"CC0","license_restricted":false}