When more is not better: 10 ‘don’ts’ in endometriosis management. An ETIC* position statement

ETIC Endometriosis Treatment Italian Club, L. Alio, Stefano Angioni, Salvatore Arena, Ludovica Bartiromo, Valentino Bergamini, Nicola Berlanda, Cecilia Bonin, Mauro Busacca, Massimo Candiani, Gabriele Centini, Maurizio Nicola D’Alterio, Annalisa Di Cello, C. Exacoustós, Luigi Fedele, Maria Pina Frattaruolo, Domenico Incandela, Lucia Lazzeri, Stefano Luisi, Antonio Maiorana, Francesco Maneschi, Francesco Giuseppe Martire, Claudia Massarotti, Alberto Mattei, L Muzii, Jessica Ottolina, Alessio Perandini, Federica Perelli, Ida Pino, Maria Grazia Porpora, Diego Raimondo, Valentino Remorgida, Renato Seracchioli, Eugenio Solima, Edgardo Somigliana, Giuseppe Sorrenti, Roberta Venturella, Paolo Vercellini, Paola Viganò, M. Vignali, Fulvio Zullo, Errico Zupi
Human reproduction open · 2019 · vol. 2019(3) , pp. hoz009 · doi:10.1093/hropen/hoz009 · PMID:31206037 · PMC6560357 · W2951373423
article OA: gold CC0 ⤵ 49 in-corpus citations
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⚙ AI-generated summary by claude@2026-06, 2026-06-07 ⓘ

A panel of endometriosis experts identified ten low-value interventions for endometriosis management that should be discouraged to prevent harm and improve resource allocation.

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Abstract

A network of endometriosis experts from 16 Italian academic departments and teaching hospitals distributed all over the country made a critical appraisal of the available evidence and definition of 10 suggestions regarding measures to be de-implemented. Strong suggestions were made only when high-quality evidence was available. The aim was to select 10 low-value medical interventions, characterized by an unfavorable balance between potential benefits, potential harms, and costs, which should be discouraged in women with endometriosis. The following suggestions were agreed by all experts: do not suggest laparoscopy to detect and treat superficial peritoneal endometriosis in infertile women without pelvic pain symptoms; do not recommend controlled ovarian stimulation and IUI in infertile women with endometriosis at any stage; do not remove small ovarian endometriomas (diameter <4 cm) with the sole objective of improving the likelihood of conception in infertile patients scheduled for IVF; do not remove uncomplicated deep endometriotic lesions in asymptomatic women, and also in symptomatic women not seeking conception when medical treatment is effective and well tolerated; do not systematically request second-level diagnostic investigations in women with known or suspected non-subocclusive colorectal endometriosis or with symptoms responding to medical treatment; do not recommend repeated follow-up serum CA-125 (or other currently available biomarkers) measurements in women successfully using medical treatments for uncomplicated endometriosis in the absence of suspicious ovarian cysts; do not leave women undergoing surgery for ovarian endometriomas and not seeking immediate conception without post-operative long-term treatment with estrogen-progestins or progestins; do not perform laparoscopy in adolescent women (<20 years) with moderate-severe dysmenorrhea and clinically suspected early endometriosis without prior attempting to relieve symptoms with estrogen-progestins or progestins; do not prescribe drugs that cannot be used for prolonged periods of time because of safety or cost issues as first-line medical treatment, unless estrogen-progestins or progestins have been proven ineffective, not tolerated, or contraindicated; do not use robotic-assisted laparoscopic surgery for endometriosis outside research settings. Our proposal is to better address medical and surgical approaches to endometriosis de-implementing low-value interventions, with the aim to prevent unnecessary morbidity, limit psychological distress, and reduce the burden of treatment avoiding medical overuse and allowing a more equitable distribution of healthcare resources.

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endometriosisdysmenorrhea

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