Effect of postoperative hormonal therapy on pain following endometriosis surgery: a retrospective cohort study

Background Endometriosis is heterogeneous, and evidence for individualised postoperative management is limited. We assessed whether postoperative hormonal therapy exposure is associated with one-year changes in pain domains after first-time endometriosis surgery and explored factors related to treatment allocation.

Retrospective cohort study (Erlangen, 09/2019–06/2024) of premenopausal women (18–45 years) undergoing first minimally invasive surgery for endometriosis-associated pain with one-year follow-up. Patients were classified into four hormonal therapy (HT) patterns based on baseline and follow-up status: HT none (n = 73), HT initiation (n = 57), HT discontinuation (n = 21), and HT continuation (n = 38). For each pain domain, adjusted analysis of covariance (ANCOVA) models estimated one-year follow-up Numeric Rating Scale (NRS) differences, and therapy-group effects were tested using robust Wald omnibus tests with Holm multiplicity adjustment across domains, and post-hoc contrasts were Holm-adjusted within domains and interpreted only for domains with significant omnibus tests. HT-group membership was analysed using multinomial logistic regression.

After multiplicity adjustment across domains, therapy-group differences were observed only for dysmenorrhoea/pelvic pain (p < 0.001). Within this domain, only HT initiation was associated with lower one-year follow-up scores versus HT none (adjusted difference −2.39 NRS points, 95% confidence interval (CI) −3.58 to −1.21; p < 0.001), whereas other contrasts were not significant after within-domain multiplicity correction. No domain-level evidence of between-group differences was found for dyspareunia, dysuria, or dyschezia. Younger age was associated with HT initiation (odds ratio (OR) 0.92, 95% CI 0.86–0.98; p = 0.012) and continuation (OR 0.82, 95% CI 0.74–0.91; p < 0.001).

HT initiation was associated with lower one-year dysmenorrhoea/pelvic pain scores, while other domains showed no consistent differences. Younger patients were more likely to initiate or continue hormonal therapy, suggesting non-random allocation. Given the observational design and potential residual confounding, findings are hypothesis-generating and support symptom-profile-guided postoperative management; prospective studies with standardised regimens and domain-specific outcomes are needed. PLAIN LANGUAGE SUMMARY Endometriosis can cause different kinds of pain. This may include period-related pain in the lower abdomen (pelvic pain), pain during sex, pain when passing urine, and pain during bowel movements. Surgery can remove visible endometriosis lesions. Many women are advised to use hormone treatment, but it is not clear whether this helps all types of pain in the same way. We looked at information from women aged 18–45 years who had their first keyhole surgery for endometriosis-related pain and completed a follow-up questionnaire one year later at our specialist centre in Erlangen, Germany. We compared four groups: women who did not use hormone treatment at all, women who started hormone treatment after surgery, women who stopped hormone treatment by the one-year follow-up, and women who used hormone treatment both before surgery and at follow-up. Most women reported that their symptoms improved one year after surgery. When we compared the groups, the clearest difference was for period-related lower abdominal pain: women who started hormone treatment after surgery improved more than women who stopped hormone treatment or did not use it. For pain during sex, urination, or bowel movements, we did not see the same pattern. Younger women were more likely to start or continue hormone treatment. Because this study looked back at existing records rather than assigning treatments, we cannot prove that hormone treatment caused the improvement. Overall, hormone treatment after surgery may be most helpful for period-related pelvic pain, while other pain symptoms may need additional or different approaches.

Endometriosis is a complex condition with heterogeneous clinical presentations. Pain and infertility are considered the predominant manifestations (Maulenkul et al. Citation2024), yet symptom severity does not reliably reflect disease extent, and correlations between surgical staging and symptom profiles remain inconsistent (Conroy et al. Citation2021). Consequently, diverse phenotypes and symptom constellations are often subsumed under a single diagnostic label, complicating patient-centred decision-making and limiting the delivery of genuinely individualised, evidence-based care. This heterogeneity complicates interpretation of therapeutic effectiveness. Evidence for surgical and medical management is variable (Bafort et al. Citation2020, Chen et al. Citation2020), and effects may differ by symptom profile rather than phenotype alone. Moreover, the mechanisms linking endometriosis pathophysiology to clinical manifestation remain incompletely understood (Masciullo et al. Citation2021, Psilopatis et al. Citation2024), limiting the ability to match interventions to those patients most likely to benefit. We therefore examined one-year changes in domain-specific pain after first-time endometriosis surgery and their association with postoperative hormonal therapy exposure, classified according to hormonal therapy use at baseline and at one-year follow-up. By focusing on distinct pain domains rather than a single global pain measure, we aimed to better characterise symptom-profile-specific associations. We hypothesised that postoperative hormonal therapy initiation or continuation would be associated with lower one-year dysmenorrhoea/pelvic pain scores compared with no hormonal therapy, whereas associations for non-menstrual pain domains would be less consistent.

Setting For this retrospective cohort study, data were obtained from the International Endometriosis Evaluation Program (IEEP) project at the University Endometriosis Centre Franconia, Erlangen University (Burghaus et al. Citation2016). Patients undergoing surgery for suspected endometriosis completed a standardised preoperative questionnaire on medical history, symptoms, prior treatments and fertility. At the one-year postoperative follow-up all patients completed a standardised questionnaire. Study data were supplemented postoperatively with clinical information from the medical records. Patient selection Patients with an initial diagnosis of endometriosis between 09/2019 and 06/2024 who had undergone a first surgical treatment using a minimally invasive approach, in which endometriosis lesions were removed and/or ablated, were eligible for inclusion. In line with the European Society of Human Reproduction and Embryology (ESHRE) guideline (Becker et al. Citation2022), endometriosis phenotype (superficial peritoneal, endometrioma, and deep infiltrating endometriosis (DIE)) was confirmed visually at laparoscopy and/or histologically. Adenomyosis was assessed preoperatively by ultrasound according to the Morphological Uterus Sonographic Assessment (MUSA) criteria (Harmsen et al. Citation2022), supplemented by the question-mark sign (Andres et al. Citation2018), and/or confirmed histologically. To assess potential selection due to loss to follow-up, baseline characteristics were compared between women who completed the one-year follow-up and those who did not, using standardised mean differences. After applying all exclusion criteria, the study cohort consisted of 189 premenopausal patients aged 18–45 years who underwent a first laparoscopy for endometriosis-associated pain. Patients presenting with infertility were excluded because management priorities differ and cycle-suppressing hormonal therapy is generally avoided during fertility treatment and often deferred until after its completion. Patients who were pregnant at baseline or at follow-up were excluded to avoid potential interference with postoperative hormonal pain management. Women with hysterectomies were excluded due to unavailable information on dysmenorrhoea. In addition, patients who underwent reintervention during the observation period were excluded. The study size was determined by the number of eligible patients with one-year follow-up available during the study period; no a priori sample size calculation was performed. Data collection Pain intensity was assessed using the Numeric Rating Scale (NRS; 0–10) for dysmenorrhoea/pelvic pain, dyspareunia, dysuria, and dyschezia and analysed as domain-specific primary outcomes. A composite score (sum of the four domain-specific NRS scores; range 0–40) was derived, and a single global follow-up item (improved/unchanged/worsened) was collected. Patients were classified into four groups based on hormonal therapy at baseline and at one-year follow-up: no hormonal therapy at baseline and follow-up (HT none), no hormonal therapy at baseline and hormonal therapy at follow-up (HT initiation), hormonal therapy at baseline and no hormonal therapy at follow-up (HT discontinuation), and hormonal therapy at baseline and follow-up (HT continuation). Groups reflect hormonal therapy status at baseline and at one-year follow-up; initiation/discontinuation refers to changes between these two time points. Follow-up hormonal therapy use reflects self-reported status at one year and does not capture adherence or interim regimen changes. To examine group differences, we calculated the change in NRS pain scores as baseline minus follow-up. Positive values indicated a reduction in pain intensity. Statistical analysis Statistical analysis was performed using SPSS version 29.0 and R version 4.5.1. Continuous data are summarised as mean (standard deviation, SD) for interpretability. Time from baseline to follow-up is reported as a median (interquartile range, IQR). Distributional assumptions were assessed descriptively using the Shapiro-Wilk test and graphical inspection. Baseline characteristics were presented descriptively by study group (n (%), mean (SD)), and no hypothesis tests were performed for baseline between-group differences. Categorical clinical features (e.g., endometrioma, DIE, adenomyosis) were included as covariates in the adjusted outcome models and, where applicable, as predictors in the multinomial logistic regression used to examine factors associated with group membership. Model diagnostics further included inspection of residual and leverage plots and screening for influential observations using leverage and Cook’s distance. Between-group comparisons were assessed using adjusted analysis of covariance (ANCOVA)-style linear models. For each pain domain, the one-year follow-up NRS score was modelled as the dependent variable with therapy group as the exposure (reference: HT none), adjusting for the corresponding baseline NRS score, age at baseline, and phenotype markers (adenomyosis, endometrioma, and DIE). Models were fitted as complete-case within each domain, and inference used heteroskedasticity-consistent (HC3) robust standard errors and robust Wald omnibus tests for the therapy-group factor. Multiplicity across the four pain domains was controlled using Holm adjustment of the domain-level omnibus p-values; post-hoc contrasts versus the reference group were examined only where the domain-level omnibus test indicated evidence of a therapy-group effect, with Holm adjustment across the three contrasts. Model diagnostics included assessment of homogeneity of regression slopes; where this assumption was not supported (dysuria), we performed a sensitivity analysis including a therapy group-by-baseline interaction and interpreted dysuria group contrasts cautiously. As an exploratory robustness check, we repeated the adjusted models for dysmenorrhoea/pelvic pain stratified by baseline hormonal therapy status (non-users vs users); other pain domains were not stratified due to small stratum sizes, and results were interpreted descriptively. Unadjusted within-group changes were described using Wilcoxon signed-rank tests in participants with baseline NRS > 0 and paired observations to illustrate the direction and magnitude of observed change (baseline NRS = 0 excluded to minimise floor effects). ΔNRS was defined as baseline—follow-up (positive values indicate improvement). To characterise non-random treatment allocation and potential confounding by indication, predictors of therapy-group membership were explored using multinomial logistic regression, including baseline composite pain score, age, and the presence of adenomyosis, endometrioma, and DIE. Baseline pain severity was represented by the composite pain score to limit model complexity. No multiplicity adjustment was applied across pain domains for the descriptive non-parametric tests; p-values are reported to describe patterns across domains and should be interpreted cautiously. Mode of administration and type of hormonal therapy at follow-up were summarised descriptively. No imputation was performed; models were fitted as complete-case, and sample size therefore, varied by domain. Statistical significance was defined as p < 0.05. Ethical approval was granted by the medical faculty’s ethics committee (ethical approval registration number: 255_18 B), and all participants provided written informed consent.

Demographic data Of 1992 women screened, 569 completed the one-year follow-up questionnaire and were assessed for eligibility; 380 were excluded, leaving 189 patients in the final cohort (). The median follow-up was 373 days (IQR 360–388). Baseline characteristics were broadly comparable between women who did and did not complete one-year follow-up; however, completers reported moderately higher baseline pain (pelvic pain, dyspareunia, and dyschezia), suggesting differential follow-up by symptom burden (Supplementary table 1). The mean age at presentation was 30.8 years (SD 6.9), with a mean body mass index (BMI) of 23.1 kg/m2. Endometrioma was recorded in 28.6% of the patients, 29.1% had DIE, and 18.5% had adenomyosis. Participants were classified into four perioperative hormonal therapy groups: HT none (n = 73, 38.6%), HT initiation (n = 57, 30.2%), HT discontinuation (n = 21, 11.1%), and HT continuation (n = 38, 20.1%). Women in the HT initiation and HT continuation groups were younger on average (29.9 and 28.2 years, respectively) than those in the HT none group (33.0 years), while BMI was broadly similar across groups. Baseline pain severity was comparable between groups (mean dysmenorrhoea/pelvic pain NRS 7.0–7.9). At follow-up, dysmenorrhoea/pelvic pain was lowest in the HT initiation group (2.4 ± 2.9) and highest in the HT discontinuation group (4.8 ± 3.5). Overall change in pain symptoms was assessed using a patient-reported global item at follow-up (improved/unchanged/worsened). At one year, 81.0% of all patients reported an improvement in pain symptoms; improvement was most frequent in the HT initiation group (91.2%) and least frequent in the HT discontinuation group (66.7%). Adenomyosis was less common in the HT initiation group (8.8%) than in the other groups (19.2–28.6%), whereas endometrioma and DIE showed a broadly similar distribution across groups. Hormonal therapy use was reported by 31.2% (n = 59) at baseline and by 50.3% (n = 95) at follow-up. Baseline characteristics are shown in , and unadjusted one-year follow-up outcomes are shown in . Hormonal therapy regimens at follow-up are summarised in Supplementary Table 2. Change in pain intensity Across domains, evidence of a therapy-group effect after multiplicity control was observed only for dysmenorrhoea/pelvic pain (χ2 = 19.58, df = 3, p < 0.001); dyspareunia, dysuria, and dyschezia showed no such evidence. For dysuria, model diagnostics suggested non-homogeneous baseline slopes; however, given the non-significant omnibus test, no further between-group contrasts were pursued. Within dysmenorrhoea/pelvic pain, HT initiation was associated with lower one-year follow-up scores compared with HT none (adjusted difference −2.39 NRS points, 95% confidence interval (CI) −3.58 to −1.21; p < 0.001). HT continuation showed a nominal association with lower follow-up pelvic pain compared with HT none (−1.55, 95% CI −3.00 to −0.10; p = 0.037), but this did not remain significant after within-domain multiplicity correction (Holm-adjusted p = 0.074), whereas HT discontinuation showed no clear differences. Complete-case sample sizes for the adjusted models ranged from n = 126 to n = 143 across domains (). Baseline and follow-up NRS values, with therapy-group sample sizes and missingness per domain, are shown in Supplementary Table 3. In exploratory stratified adjusted models for dysmenorrhoea/pelvic pain, the association was consistent among baseline non-users (HT initiation vs. HT none: −2.40, 95% CI −3.62 to −1.18; p < 0.001). Among baseline users, HT continuation versus HT discontinuation showed a directionally similar but imprecise estimate (−1.97, 95% CI −4.14 to 0.20; p = 0.074), consistent with limited stratum sizes (Supplementary Table 4). In descriptive paired analyses restricted to participants with baseline NRS > 0 and paired baseline and one-year follow-up observations, within-group changes were summarised using the Wilcoxon signed-rank test (Supplementary Table 5). Improvements were generally observed across most pain domains, whereas dysuria in the HT discontinuation group showed no clear within-group change. Factors associated with therapy-group membership In multinomial logistic regression, the full model improved fit compared with the intercept-only model (likelihood ratio χ2 = 28.556, df = 15, p = 0.018). Baseline age was inversely associated with membership in the HT initiation group (OR 0.921, 95% CI 0.863–0.982; p = 0.012) and the HT continuation group (OR 0.821, 95% CI 0.738–0.914; p < 0.001) compared with HT none, whereas baseline composite pain score and phenotype markers were not clearly associated with group membership (Supplementary Table 6). These findings indicate non-random treatment allocation, with younger patients more likely to initiate or continue hormonal therapy, and support the potential for confounding by indication.

Summary of the main results In this retrospective cohort of premenopausal patients undergoing first-time surgery for endometriosis-associated pain, most participants reported symptomatic improvement at one year, with 81% indicating overall improvement on a global patient-reported item. Domain-specific NRS scores generally decreased within therapy groups across most pain domains. In adjusted between-group analyses using an ANCOVA framework with robust standard errors, evidence of between-group differences in one-year follow-up scores was confined to dysmenorrhoea/pelvic pain, supported by a significant domain-level omnibus test that remained significant after adjustment for multiple pain domains. Within this domain, postoperative hormonal therapy initiation was associated with lower one-year follow-up dysmenorrhoea/pelvic pain compared with no hormonal therapy, and this association persisted after correction for multiple contrasts. Hormonal therapy continuation showed a directionally similar, nominal association versus no hormonal therapy but did not remain statistically significant after within-domain multiplicity correction; discontinuation did not show a clear difference. Consistent with the non-significant domain-level omnibus tests, no between-group differences were observed for dyspareunia, dysuria, or dyschezia. Multinomial regression suggested non-random treatment allocation, with younger age being associated with hormonal therapy initiation and continuation. Interpretation and possible explanations The overall improvement reported by most patients likely reflects a combination of factors, including surgical removal/ablation of endometriosis lesions, perioperative counselling and follow-up care, and subsequent optimisation of pharmacological and non-pharmacological management. The domain-specific association observed for dysmenorrhoea/pelvic pain is clinically plausible: menstrual-related pelvic pain may be more responsive to postoperative hormonal suppression through reduction of cyclical activity and inflammatory pathways (Machairiotis et al. Citation2021). The exploratory stratified analysis for dysmenorrhoea/pelvic pain suggested that the observed pattern was not confined to a single baseline hormonal-therapy context, although the baseline-user stratum was underpowered and estimates should be interpreted cautiously. In contrast, dyspareunia, dysuria, and dyschezia are heterogeneous symptoms and may be influenced by additional mechanisms (e.g., pelvic floor dysfunction, neuropathic pain components, bowel/bladder comorbidity, or coexisting conditions). These mechanisms may not be adequately addressed by hormonal therapy alone, supporting an individualised, multimodal approach for persistent non-menstrual pain domains and consideration of alternative or additional diagnoses when symptoms do not improve. The association between younger age and hormonal therapy initiation/continuation may reflect prescribing patterns, differences in tolerance or preferences, contraceptive needs, or clinician perceptions regarding benefit-risk profiles. In the adjusted ANCOVA models, age was also independently associated with follow-up pain in selected domains. These analyses address different questions—predictors of treatment allocation versus predictors of follow-up pain—and should not be interpreted as establishing a causal pathway. Together, these findings reinforce the likelihood of confounding by indication and the need for cautious interpretation of between-group associations. Postoperative hormonal therapy was recommended to symptomatic patients in accordance with current guidelines (Becker et al. Citation2022). However, prescriptions were commonly issued in outpatient care, and uptake at one year remained limited: although hormonal therapy use increased from baseline to follow-up, only half of the cohort reported ongoing use at one year. This gap between recommendation and real-world use may reflect tolerability, preferences, access to follow-up care, or switching between regimens and may contribute to heterogeneity in observed outcomes in routine practice. Data on real-world persistence and adherence to postoperative hormonal therapy in endometriosis are limited, and further research is needed to quantify continuation patterns and their impact on outcomes. Comparison with previous work Our findings are consistent with prior studies reporting improvement in pain symptoms following laparoscopic surgery for endometriosis (Abbott et al. Citation2004, Riley et al. Citation2019), although the certainty of evidence varies and many studies do not separate distinct pain domains. Systematic reviews have described moderate-quality evidence for reduction in overall pain after surgery (Bafort et al. Citation2020), but domain-specific outcomes are less frequently reported, limiting direct comparisons (Bafort et al. Citation2020, Zakhari et al. Citation2021). The domain-specific pattern observed here—greater improvement in dysmenorrhoea/pelvic pain in association with postoperative hormonal therapy, but not across other pain domains—adds nuance to the evidence base and may help explain heterogeneous results across studies that rely on composite or global pain outcomes. Regarding postoperative hormonal therapy, the literature is mixed. Some studies suggest benefit for recurrence prevention or symptom reduction (Zakhari et al. Citation2021), whereas others question the magnitude of pain benefit (Chen et al. Citation2020). Differences in patient selection (first-time vs repeat surgery), baseline symptom profiles, disease phenotype, definitions of postoperative therapy exposure (initiation, continuation, adherence), and outcome measurement (global ratings vs domain-specific NRS) may account for discrepant findings. In addition, real-world adherence and regimen heterogeneity—both evident in our cohort—may dilute detectable effects in observational settings. Our data, therefore, support the interpretation that hormonal therapy effects may be symptom-profile dependent rather than uniform across all endometriosis-associated pain domains. Strengths and weaknesses Key strengths include the use of standardised patient-completed questionnaires for baseline and follow-up assessment, which supports consistency of symptom capture, and the focus on a clinically relevant subgroup: premenopausal patients undergoing first-time surgery for endometriosis-associated pain without infertility-related indications. The one-year follow-up interval is meaningful for postoperative management decisions, as treatment initiation, switching, and discontinuation commonly occur within this period. Several limitations warrant consideration. First, the retrospective observational design and non-random treatment allocation limit causal inference; residual confounding is likely, including confounding by indication. Although adjusted models accounted for baseline pain severity, age, and phenotype markers, unmeasured factors such as treatment adherence, regimen changes over time, analgesic use, comorbid pain conditions, psychosocial factors, and surgical extent may have influenced outcomes. In addition, the hormonal-therapy exposure groups comprise heterogeneous regimens. Second, subgroup sizes were small for some therapy groups and pain domains, reducing precision and power, particularly for less prevalent symptoms and stratified comparisons among baseline hormonal therapy users. Third, adjusted models were fitted as complete cases within each domain, and selection bias is possible if missing data were not random. Fourth, the one-year follow-up may not capture longer-term recurrence trajectories in this chronic condition (Veth et al. Citation2024). Finally, as this is a single-centre cohort from a specialist endometriosis unit and restricted to first-time surgery for pain without infertility-related indications, generalisability to broader populations and care settings may be limited. In conclusion, our results suggest that postoperative hormonal therapy is associated with improved dysmenorrhoea/pelvic pain at one year, while effects are not consistent across other pain domains. These findings support symptom-profile-guided postoperative management and highlight the need for adequately powered prospective studies with standardised regimen definitions and domain-specific outcomes to clarify which patients benefit most from hormonal therapy and how best to address persistent non-menstrual pain symptoms. Supplemental material Supplemental Material Download MS Word (45.7 KB)Supplemental MaterialAcknowledgments OpenAI GPT-5.2 was used to assist with language editing and manuscript drafting; all scientific content and interpretations were reviewed and approved by the authors. To improve readability and consistency and reduce errors. Disclosure statement Prof. Dr. Matthias W. Beckmann reports support for attending meetings and/or travel from various meetings and social events. PD Dr. Stefanie Burghaus reports receiving honoraria for a presentation at the Forum Medizinische Fortbildung (FOMF) and for a manuscript contribution to Forum Sanitas. She serves in an unpaid leadership role within the Arbeitsgemeinschaft Endometriose (AGEM). Prof. Dr. Peter A. Fasching reports grants or contracts from Biontech, Cepheid, and Pfizer to his institution. He has received consulting fees, honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events, and participated on data safety monitoring or advisory boards for Novartis, Pfizer, Roche, Daiichi-Sankyo, AstraZeneca, Lilly, Eisai, Merck Sharp & Dohme, Pierre Fabre, SeaGen, Agendia, Sanofi Aventis, Gilead, and Mylan, all paid directly to himself. All other authors report there are no competing interests to declare. Data availability statement The participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available. Additional information Funding

- Abbott, J., et al., 2004. Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. Fertility and Sterility, 82 (4), 878–884. - Andres, M.P., et al., 2018. Transvaginal ultrasound for the diagnosis of adenomyosis: systematic review and meta-analysis. Journal of Minimally Invasive Gynecology, 25 (2), 257–264. - Bafort, C., et al., 2020. Laparoscopic surgery for endometriosis. The Cochrane Database of Systematic Reviews, 10 (10), CD011031. - Becker, C.M., et al., 2022. ESHRE guideline: endometriosis. Human Reproduction Open, 2022 (2), hoac009. - Burghaus, S., et al., 2016. The international endometriosis evaluation program (IEEP Study)—a systematic study for physicians, researchers and patients. Geburtshilfe Und Frauenheilkunde, 76 (8), 875–881. - Chen, I., et al., 2020. Pre- and postsurgical medical therapy for endometriosis surgery. The Cochrane Database of Systematic Reviews, 11 (11), CD003678. - Conroy, I., et al., 2021. Pelvic pain: what are the symptoms and predictors for surgery, endometriosis and endometriosis severity. The Australian & New Zealand Journal of Obstetrics & Gynaecology, 61 (5), 765–772. - Harmsen, M.J., et al., 2022. Consensus on revised definitions of morphological uterus sonographic assessment (MUSA) features of adenomyosis: results of modified Delphi procedure. Ultrasound in Obstetrics & Gynecology: The Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology, 60 (1), 118–131. - Machairiotis, N., Vasilakaki, S. and Thomakos, N., 2021. Inflammatory mediators and pain in endometriosis: a systematic review. Biomedicines, 9 (1), 54. - Masciullo, L., et al., 2021. A deep insight into pelvic pain and endometriosis: a review of the literature from pathophysiology to clinical expressions. Minerva Obstetrics and Gynecology, 73 (5), 511–522. - Maulenkul, T., et al., 2024. Understanding the impact of endometriosis on women’s life: an integrative review of systematic reviews. BMC Women’s Health, 24 (1), 524. - Psilopatis, I., et al., 2024. The hallmarks of endometriosis. Geburtshilfe Und Frauenheilkunde, 84 (6), 555–563. - Riley, K.A., et al., 2019. Surgical excision versus ablation for superficial endometriosis-associated pain: a randomized controlled trial. Journal of Minimally Invasive Gynecology, 26 (1), 71–77. - Veth, V.B., et al., 2024. Recurrence after surgery for endometrioma: a systematic review and meta-analyses. Fertility and Sterility, 122 (6), 1079–1093. - Zakhari, A., et al., 2021. Endometriosis recurrence following post-operative hormonal suppression: a systematic review and meta-analysis. Human Reproduction Update, 27 (1), 96–107.