Management of Women with Endometriosis in Pakistan: Good Clinical Practice Recommendations

Shams-un-Nisa Sadia, Tasneem Akhtar, Zartaj Hayat, Syeda Batool Mazhar, Nabia Tariq, Sadaqat Jabeen, Zahra Muslim, Nadeem Zuberi, Ghazala Mahmud, Amer Raza, Rizwana Chaudhri, Saima Zubair, Rubina Mushtaq
In: Journal of The Society of Obstetricians and Gynaecologists of Pakistan · 2026 · vol. 16(1) , pp. 77–88 · doi:10.71104/jsogp.v16i1.1012 · W7129034566
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These Good Clinical Practice recommendations for Pakistan outline endometriosis management strategies including diagnosis, medical treatments, surgical options, and fertility interventions tailored to specific patient populations.

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This paper presents Good Clinical Practice recommendations for managing endometriosis in Pakistan, emphasizing that a careful history is the diagnostic cornerstone while laparoscopy remains non-mandatory. The guidelines outline a stepped medical treatment approach starting with NSAIDs and hormonal contraceptives, progressing to GnRH agonists or aromatase inhibitors, alongside integrated psychosocial support. Surgical management favors excision over ablation, with specific protocols for endometriomas and fertility preservation strategies that distinguish between natural conception and IVF based on disease severity. This paper is centrally about endometriosis — specifically providing localized clinical practice guidelines for diagnosis, medical therapy, surgery, and fertility management within the Pakistani healthcare context.

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Abstract

Executive summary Diagnosis: A careful history is the cornerstone. Imaging supports diagnosis. Laparoscopy is not mandatory for diagnosis; empirical medical treatment is a valid first step. Medical Treatment: First-line: NSAIDs + Combined Oral Contraceptives or Progestogens. Second-line: GnRH agonists/antagonists with add-back therapy. Third line: Aromatase inhibitors (used with caution). Evaluate every 6–12 months for efficacy and side effects. Lifestyle & Psychosocial Lifestyle & Psychosocial: Mental Health: Integrate Cognitive Behavioral Therapy (CBT), mindfulness, and psychosocial support. Surgery: Excision is preferred over ablation. Laparoscopic cystectomy is standard for endometriomas >3-4cm. Drainage with sclerotherapy is option in selected patients. Avoid repeated surgeries. Fertility: Do not use hormonal suppression to improve fertility. Determination of ovarian reserve before treatment is prognostically important. Surgery may improve natural conception (ASRM I–II); IVF preferred for advanced disease (ASRM III–IV); pre-treatment with GnRH agonists for 3+ months is beneficial. Special Populations: Adolescents: Have a high index of suspicion. Postmenopausal Women: Menopausal Hormone Therapy (MHT) can be used but requires careful counselling.
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Management of Women with Endometriosis in Pakistan: Good Clinical Practice Recommendations Abstract Executive summary Diagnosis: A careful history is the cornerstone. Imaging supports diagnosis. Laparoscopy is not mandatory for diagnosis; empirical medical treatment is a valid first step. Medical Treatment: First-line: NSAIDs + Combined Oral Contraceptives or Progestogens. Second-line: GnRH agonists/antagonists with add-back therapy. Third line: Aromatase inhibitors (used with caution). Evaluate every 6–12 months for efficacy and side effects. Lifestyle & Psychosocial Lifestyle & Psychosocial: Mental Health: Integrate Cognitive Behavioral Therapy (CBT), mindfulness, and psychosocial support. Surgery: Excision is preferred over ablation. Laparoscopic cystectomy is standard for endometriomas >3-4cm. Drainage with sclerotherapy is option in selected patients. Avoid repeated surgeries. Fertility: Do not use hormonal suppression to improve fertility. Determination of ovarian reserve before treatment is prognostically important. Surgery may improve natural conception (ASRM I–II); IVF preferred for advanced disease (ASRM III–IV); pre-treatment with GnRH agonists for 3+ months is beneficial. Special Populations: Adolescents: Have a high index of suspicion. Postmenopausal Women: Menopausal Hormone Therapy (MHT) can be used but requires careful counselling. Copyright (c) 2026 Journal of The Society of Obstetricians and Gynaecologists of Pakistan This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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