{"paper_id":"f132b10e-f65e-4801-b0b5-3538a9d229d7","body_text":"10\nFlagship  ●  June 2026  ●  Copyright © 2026 EMJ  ●  CC BY-NC 4.0 Licence\nManaging Endometriosis-Associated \nPain: A Two-Step Approach\nCongress Feature\nTHE BURDEN AND  \nLONG-TERM MANAGEMENT  \nOF ENDOMETRIOSIS\nRecent research indicates that deep \ninfiltrating endometriosis requires a \nstructured approach and long-term \npostoperative treatment.1 Such treatment \nhelps slow the pathological processes \nthat create an aggressive peritoneal \nenvironment, drive cellular changes, and \nultimately contribute to recurrence.\nEndometriosis has a major impact on \nwomen’s quality of life. Around 70% of \nwomen with the condition experience \nchronic pelvic pain of varying severity, and \none in two experience infertility.2,3\nSURGERY AND RISK  \nOF RECURRENCE\nMost patients with endometriosis undergo \nsurgery, although it does not address the \nunderlying cause of the disease.4 Surgery \naims to remove as much diseased tissue as \npossible, relieve pain, improve quality of life, \nand reduce the risk of recurrence.4\nSurgery can lead to complications, \nparticularly when the bowel, bladder, or \nuterus is involved.4 It may also reduce \novarian reserve, increasing the risk of \niatrogenic premature ovarian insufficiency.4,5 \nRecurrence rates can reach 50%, even \nafter successful surgery.4,6 Bezhenar noted: \n“Unjustified repeat surgeries without long-\nterm anti-recurrence therapy may worsen \nthe disease and reduce ovarian reserve.”7,8\nPOSTOPERATIVE \nHORMONAL THERAPY\nBezhenar presented data showing that \npostoperative treatment plays a key role \nin preventing endometriosis recurrence.9-12 \nHis analysis linked repeat surgery to \nthe absence of hormonal therapy. In the \nstudy, fewer than half of patients had not \nundergone previous surgery, while 14% had \none prior operation, 11% had two, and 2% \nhad three or more.9-12\nMost recurrences occurred after hormonal \ntherapy was discontinued. Around 80% of \npatients stopped treatment themselves, \nwhile in 22% of cases it was stopped by  \nthe gynaecologist.13\nTWO-STEP APPROACH\nThe Russian Society of Obstetricians and \nGynaecologists (RSOG) recommends a \nAuthor: Alena Sofieva, EMJ, London, UK \nCitation: EMJ. 2026;11[2]:10-13. https://doi.org/10.33590/emj/ZEC0NY0Z\nAT THIS year’s International Society of Gynaecological Endocrinology (ISGE) \nCongress 2026, held in Rome, Italy, Vitaly F. Bezhenar, Head of the Department \nof Obstetrics, Gynaecology, and Neonatology at First Pavlov State Medical \nUniversity of St. Petersburg, Russia, reviewed the current approach to the management \nof endometriosis-associated pain. He explored the recommended two-step treatment \nstrategy, compared different postoperative hormonal therapies, and discussed the role \nof long-term medical management in reducing recurrence and improving quality of life in \nwomen with endometriosis.\n\nCC BY-NC 4.0 Licence  ●  Copyright © 2026 EMJ  ●  June 2026  ●  Flagship\n11\ncombined two-step approach: surgery \nwhen indicated, followed by postoperative \nhormone-modulating therapy for at least \n6 months if pregnancy is planned, and \nlonger if it is not.14 Laparoscopic surgery \nis preferred for deep endometriosis, and \ntreatment should always be individualised.14\nTreatment decisions should be based not \nonly on clinical factors, but also on the \nmorphological features of the excised \ntissue. In Bezhenar’s study, microscopic foci \nof endometrioid heterotopia were found in \n50% of samples taken from macroscopically \nintact peritoneum.15 Bezhenar concluded: \n“These findings support the need for \npostoperative hormonal therapy to  \nprevent disease recurrence.”\nCONSERVATIVE MANAGEMENT \nAND PAIN CONTROL\nIn a separate study of conservative \nstrategies for endometriosis-associated \npain, including non-pharmacological, anti-\ninflammatory, and hormonal treatments, \n71% of women reported no symptom \nimprovement.13 A further 23% reported \nonly slight improvement, while significant \npain reduction was seen in just 5% of \npatients.13 Complete pain relief was \nachieved in only 4%.13\nBezhenar compared these findings with \nanother study of 178 patients who had \nundergone surgery for endometriosis.11 \nAfter surgery, 82 patients (46.1%) received \ngonadotropin-releasing hormone (GnRH) \nagonists, 58 (32.6%) received dienogest, \nand 21 (11.8%) received combined oral \ncontraceptive (COC) pills containing \ndienogest. A further 17 women (9.5%) were \nplanning pregnancy and therefore received \nno hormonal therapy. Postoperative \ntreatment lasted 4–6 months.11\nThe study assessed the proportion of \npatients reporting significant reductions \nin endometriosis-associated pain after \ndifferent treatments. The highest rates \nwere seen with GnRH agonists (40%) and \ndienogest (38%). Patients receiving these \ntreatments also reported improved quality \nof life and sexual function.11\nPROGESTAGENS AS  \nFIRST-LINE THERAPY\nAccording to the RSOG, progestagens are \nrecommended as first-line therapy.14 They \ncan be given continuously to promote \nglandular epithelial atrophy and stromal \ndecidualisation, although cyclic use may be \nconsidered for patients planning pregnancy.16\nBezhenar and colleagues reported that COCs \nare not suitable for anti-relapse therapy in \nendometriosis and should be used only for \ncontraception.17 In their study, patients who \nreceived cyclic COCs containing 30 mcg \nethinylestradiol (EE) and dienogest had the \nlowest pregnancy rates and the highest \nrecurrence rates of pelvic endometriosis.\nAll recurrences after cyclic therapy with  \n30 mcg EE and dienogest were associated \nwith endometrioid infiltrates identified \nduring repeat laparoscopy that had not \nbeen detected at the initial surgery.17\nDIENOGEST VERSUS COCs\nThe authors compared the effects of \ndienogest 2 mg with those of COCs. \nDienogest was associated with a moderate \nreduction in oestrogen levels while \nmaintaining concentrations within the \ntherapeutic window (30–60 pg/mL).18 It \nwas also shown to reduce several forms of \nendometriosis-associated pain, including \npelvic pain, dysmenorrhoea, dyspareunia, \ndysuria, and dyschezia.\nIn contrast, COCs may disrupt the \noestrogen–progestin balance when \noestrogen doses exceed physiological \nlevels, potentially promoting endometriosis \nprogression.18 Although COCs may reduce \ndysmenorrhoea, they were not shown \nto relieve dyspareunia or non-cyclical \npelvic pain. Women using COCs for \ndysmenorrhoea were later diagnosed with \nsevere infiltrative endometriosis.18 \n \n \n \nCongress Feature\n\n12\nFlagship  ●  June 2026  ●  Copyright © 2026 EMJ  ●  CC BY-NC 4.0 Licence\nQUALITY OF LIFE AND \nRECURRENCE OUTCOMES\nA real-world study showed that dienogest \n2 mg was associated with a significant \nreduction in chronic pelvic pain and \nimproved quality of life in women with \nendometriosis.19 The ENVISION study \nincluded 865 Asian women from 36 clinics \nacross Asia.19\nImprovements were reported across all \nquality-of-life domains during treatment \nwith dienogest 2 mg.19 Quality of life was \nmeasured using the Endometriosis Health \nProfile-30 (EHP-30), which assessed \npain, self-control, emotional status, social \nfunction, and self-esteem.19 The greatest \nimprovement was seen in pain scores \n(78.4%), followed by self-control (70.5%), \nemotional status (61.3%), social function \n(55.4%), and self-esteem (42.1%).19\nA systematic review and meta-analysis found \nthat postoperative treatment with dienogest \n2 mg was associated with a significantly \nlower risk of endometriosis recurrence than \nno hormonal therapy.20 Recurrence occurred \nat a rate of 0.89 per 1,000 woman-months in \nwomen receiving dienogest, compared with \n5.46 per 1,000 woman-months in controls \nwho received no therapy.20\nOver a mean follow-up of 28.5 months, \nonly two recurrences per 100 treated \nwomen were reported in the dienogest \ngroup. By comparison, 29 recurrences per \n100 women were observed over a mean \nfollow-up of 35.7 months in women who \nreceived no treatment.20\nOverall, the probability of recurrence after \nsurgery was significantly lower in patients \ntreated with dienogest than in those who did \nnot receive hormonal therapy (p<0.001).20\nCONCLUSION\nBezhenar concluded that endometriosis is a \nchronic, inflammatory, hormone-dependent \ncondition that requires long-term, \ncomprehensive management, including \npostoperative therapy. Progestogens remain \nthe first-line treatment, and continuity \nbetween inpatient and outpatient care \nis essential to optimise outcomes and \nreduce recurrence risk. He emphasised that \npostoperative therapy should continue for \nat least 6 months, and that there is no such \nthing as ‘mild’ endometriosis.\nReferences\n1. Gordts S et al. Pathogenesis of \ndeep endometriosis. Fertil Steril. \n2017;108(6):872-85.\n2. Dunselman GA et al. ESHRE \nguideline: management of women \nwith endometriosis. Hum Reprod. \n2014;29(3):400-12.\n3. Ministry of Health of the Russian \nFederation. Clinical guidelines: \nendometriosis. 2024. Available at: \nhttps://drive.google.com/file/d/14XuaZ\nzgwocmmXOXVzeVT60QK4WokgbpH/\nview. Last accessed: 13 May 2026.\n4. Chapron C et al. Rethinking \nmechanisms, diagnosis and \nmanagement of endometriosis. Nat \nRev Endocrinol. 2019;15(11):666-82.\n5. Gusev DV et al. Endometriosis-\nassociated infertility: various aspects \nof pathogenesis. Gynecology. \n2020;22(3):34-8. \n6. Ouchi N et al. Recurrence of ovarian \nendometrioma after laparoscopic \nexcision: risk factors and effect of \npostoperative hormonal treatment.  \nJ Obstet Gynaecol Res. \n2014;40(1):230-6.\n7. Harada M et al. High incidence of \nendometriosis in infertile women with \na history of surgically treated benign \novarian tumors. Gynecol Endocrinol. \n2011;27(9):717-20.\n8. Shah A et al. Catamenial \npneumothorax: a rare case of thoracic \nendometriosis. Abstract A6687.  \nATS International Conference,  \n18-23 May, 2018.\n9. Adamyan LV et al. Endometriosis: \ndiagnosis, treatment, and \nrehabilitation. Clinical guidelines. 2013. \nAvailable at: https://minzdrav.alania.\ngov.ru/sites/minzdrav/files/media/\ndocuments/files/2019-07/00002_\nЭндометриоз%202013.pdf. Last \naccessed: 13 May 2026.\n10. Bezhenar VF. Hormonal therapy in the \ntreatment of endometriosis. Innovative \nPharmacotherapy. 2022;2(6):9-12.\n11. Bezhenar VF et al. The rationale \nfor long-term hormonal therapy of \nendometriosis after surgical treatment. \nObstetrics and Gynecology (Russia). \n2021;4:134-42.\n12. European Society of Human \nReproduction and Embryology \n(ESHRE). Endometriosis guideline. \n2022. Available at: https://www.eshre.\neu/Guideline/Endometriosis. Last \naccessed: 13 May 2026.\n13. Bezhenar et al. Analysis of the \neffectiveness of various management \napproaches in patients with \nendometriosis and rationale for  \nlong-term personalized \ndydrogesterone therapy within a \ncombined treatment strategy. Prob \nReprod. 2024;30(2):102-11.\n14. Sukhikh GT et al. Algorithms for the \nmanagement of the patients with \nendometriosis: a consensus statement \nof experts from the Russian Society \nof Obstetricians and Gynecologists. \nAkush Ginekol. 2023;5:159-76.\nCongress Feature\n\nCC BY-NC 4.0 Licence  ●  Copyright © 2026 EMJ  ●  June 2026  ●  Flagship\n13\n15. Rybakova MG et al. Morphological \ncharacteristics of surgical specimens \nin nerve-sparing and conventional \ntechniques for deep infiltrating \nendometriosis. J Obstet Women's  \nDis. 2019;3-4:26-31.\n16. Busacca M et al. Guidelines \nfor diagnosis and treatment of \nendometriosis. Ital J Gynaecol Obstet. \n2018;30(2):7-21. \n17. Bezhenar VF et al. Comparison \nof the effectiveness of various \nimmunomodulatory therapy regimens \nafter surgical treatment of external \ngenital endometriosis. Prob Reprod. \n2015;4:89-98.\n18. Murji A et al. Use of dienogest in \nendometriosis: a narrative literature \nreview and expert commentary. Curr \nMed Res Opin. 2020;36(5):895-907.  \n19. Techatraisak K et al. Effectiveness of \ndienogest in improving quality of life \nin Asian women with endometriosis \n(ENVISIOeN): interim results from a \nprospective cohort study under real-life \nclinical practice. BMC Womens Health. \n2019;19:68.\n20. Zakhari A et al. Dienogest and the risk \nof endometriosis recurrence following \nsurgery: a systematic review and meta-\nanalysis. J Minim Invasive Gynecol. \n2020;27(7):1503-13.\nCongress Feature","source_license":"CC0","license_restricted":false}