Endometriosis. Emphasis on medical treatment is misleading

Editor—In his review on endometriosis, Prentice sets out management strategies for treating painful symptoms resulting from endometriosis.1 He concludes that the first line treatment should be medical and that surgery should be reserved for cases in which medical treatment has failed or for patients with severe disease. We believe that the emphasis on medical treatment and the assertion that controversy exists over the precise role of surgery are misleading and may be responsible for physicians mismanaging their patients. The evidence from randomised controlled trials for the medical and surgical management of endometriosis has recently been reviewed.2 A critical summary of the medical management has shown that there is little difference in effectiveness of various medical treatments, which only last while patients remain on treatment. The review also showed that surgical management is effective in the treatment of both painful symptoms and subfertility. Furthermore, there is a wealth of grade II and III evidence in the literature which supports laparoscopic surgery as the primary treatment modality for all stages of endometriosis.3 We believe that in the United Kingdom endometriosis is misdiagnosed in many patients who are having a laparoscopy, and many are not treated adequately because of the emphasis on medical management strategies.3 This almost certainly reflects the fact that only a few surgeons in the United Kingdom have the advanced endoscopy skills required to diagnose and then treat the disease laparoscopically. This is in marked contrast to the situation in the rest of Europe and North America, where surgical techniques using minimal access were first developed. We recommend that medical treatments be used by primary care doctors for the short to medium term to control painful symptoms, before referral to hospital for surgery or while the patient is on the waiting list for surgery. Patients should be referred to units where laparoscopic diagnosis and surgery can be carried out during the same operation. Conservative, excisional, or ablative endoscopic surgery and not medical treatment should be the first line management of patients with endometriosis. This applies to women with any stage of the disease, but particularly those with endometriotic cysts, or infiltrating rectovaginal disease.4,5 References - 1.Prentice A. Endometriosis. Regular review. BMJ. 2001;323:93–95. doi: 10.1136/bmj.323.7304.93. . (14 July.) [DOI] [PMC free article] [PubMed] [Google Scholar] - 2.Farquhar C, Sutton CJG. The evidence for the management of endometriosis. Curr Opin Obstet Gynaecol. 1998;10:321–332. doi: 10.1097/00001703-199808000-00007. [DOI] [PubMed] [Google Scholar] - 3.Garry R. Endometriosis: an invasive disease. Gynaecol Endoscopy. 2001;10:79–83. [Google Scholar] - 4.Jones KD, Sutton CJG. Laparoscopic management of ovarian endometriomas: a critical review of current practice. Curr Opin Obstet Gynaecol. 2000;12:309–317. doi: 10.1097/00001703-200008000-00008. [DOI] [PubMed] [Google Scholar] - 5.Jones KD, Sutton CJG. Arcus taurinus: the mother and father of all LUNAs. Gynaecol Endoscopy. 2001;10:83–91. [Google Scholar]