How good are the current guidelines on endometriosis?

Endometriosis is an enigmatic disorder that is fraught with management controversies and very often, there exist deep divides in management strategies among the generalist, the specialist who favours surgery, the specialist who favours medical treatment, and those who are equipoised. The lack of clarity on the aetiology of the disease fuels the existing debates and enhances subjective management options. In this issue, Hirsch et al. evaluated the methodological quality of endometriosis guidelines, mapped their recommendations and explored the relationships between the recommendations and research evidence. Included in this paper were two international and five national endometriosis guidelines, which contributed to 152 recommendations but only ten comparable recommendations. The supporting evidence used by the guidelines differed significantly, with nearly a third of recommendations unreferenced or supported by evidence; there was a lack of utilisation of standardised guideline development methods. An objective, methodical and consensual approach is an acceptable, standard way of collating evidence for guideline development. The paper, however, highlights that many guidelines developers do not engage with the necessary stakeholders or consumers, nor do they describe adequately the benefits, harms, applicability and cost of treatment. Very often, effective guideline development becomes problematic because of the variable quality of trials and their outcomes collected. The authors suggest that the development and use of a collection of well-defined, discriminatory and feasible outcomes, termed a core outcome set, would help, in part, to address these issues. It is however, reassuring that the popular guideline produced by the European Society of Human Reproduction and Embryology was objectively evaluated as the highest quality guideline. Many clinicians and trainees look to guidelines as a definitive guide for their daily clinical practice. But the more experienced, reasonable and knowledgeable will know and have learnt that guidelines are no ‘bible’ for practice, and that guidelines are as they specify, a guidance for practice. Many experienced clinicians therefore, also have their own threshold for what they perceived as sufficient evidence to change practice. Some controversies about guidelines are always expected, because the objectives of guidelines are often to address complex clinical issues, where multiple options, exceptions and uncertainties exist. Hirsch et al. highlight the imperfections that exist with the current endometriosis guidelines, and the challenges of guideline development in the context of endometriosis and have also suggested useful solutions. However, one needs to appreciate that guidelines are based on evidence drawn from a specific population, and in reality, the clinician makes decision based on an individual, often in complex circumstances that may not be reproducible in any one trial setting. Hence, as doctors, although it is in our nature to be in constant pursuit of better science, the practice of medicine will always remain an art. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.