Introduction: Management of endometriosis: moving toward a problem-oriented and patient-centered approach

Endometriosis is a protean disease, and its manifestations, associated clinical problems, and possible treatments are numerous. Deep endometriosis that infiltrates multiple pelvic organs should be considered the most severe endometriotic form that poses the most difficult therapeutic uncertainties in both infertility and pelvic pain symptoms limiting quality of life. The available evidence demonstrates that endometriosis is not only a gynecologic disorder but, contrary to previous belief, its impact extends into pregnancy, delivery, and the post-partum period. The old clinical tenet that pregnancy is a cure for endometriosis may be revealed as fallacious. Safe and effective modalities to reduce the risk of the recurrence of symptoms and lesions after conservative surgery for endometriosis are now available. These treatment options should be offered post-operatively to women not immediately seeking conception. Endometriosis is associated with a moderate increase in ovarian cancer risk. However, as there are no definitive demonstrations that endometriosis constitutes per se a pre-neoplastic condition, it seems currently unwise to set-up a screening program to detect undiagnosed endometriosis in asymptomatic women. Endometriosis is not a cancer; therefore a paradigm shift from treatment of lesions to treatment of symptoms is warranted. Management should be shaped on the main clinical problem, taking into consideration a woman's preferences and priorities. Quantitative information should be provided to describe the potential benefits, potential harms, and costs of each treatment alternative. Counseling should be complete and transparent, and the duty of the caring gynecologist is to inform the woman on the pros and cons of each option and support her in the shared decision-making process. The physician should be able to explain in detail all the available treatments, and not only those that the physician prefers or is able to offer.