Treatment of moderate and severe endometriosis

Wheeler and Malinak described a treatment algorithm that considers the severity of endometriosis, the patients' desires for reproduction versus symptom relief and the several acceptable forms of treatment, (revised AFS System) (1). The algorithm is shown in Table I (2).The management of patients with pelvic pain depends largely on the patients' age and her desire for further childbearing. In the absence of absolute indications for surgery, patients who still desire childbearing can be treated with analgesics or periodic medical therapy to reduce symptoms. Laparoscopic surgery is an alternative, particularly if it can be performed at the initial diagnostic laparoscopy. If pain continues to be severe, conservative laparotomy and presacral neurectomy with or without perioperative medical therapy should be considered. When childbearing is no longer a factor and analgesics are ineffective, definitive surgery is indicated (Table II).