Endometriosis · Medical vs Laparoscopy

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

🎓 Want to practice? Do a case challenge with this pathway → (get a case, choose management step by step, scored).

Full pathway

1. [Decision] Goal (pain/infertility) + lesions + medical response
   Main goal? Endometrioma size? Has medical therapy failed?
   • Pelvic pain, undiagnosed/can be treated empirically → Pain → empirical medical (first-line)
   • Medical failure/intolerance, or need to confirm, or large endometrioma → Failure/large cyst → laparoscopy
   • Infertility as the chief complaint → Infertility → individualized (laparoscopy/ART)
   • Refractory symptoms, completed childbearing, wants definitive treatment → Refractory/completed childbearing → definitive
2. [End] Pain → empirical medical (first-line)
   Pain empirical medical first-line (no need for prior surgery): NSAIDs + combined hormonal contraception or progestin (dienogest/LNG-IUS); second-line GnRH agonist/antagonist (± add-back), aromatase inhibitor.
3. [End] Failure/large cyst → laparoscopy
   Medical failure/need to confirm/large endometrioma → diagnostic + therapeutic laparoscopy: excise or ablate lesions, endometrioma cystectomy (excision has lower recurrence than drainage/ablation but weigh ovarian reserve), adhesiolysis; postoperative hormonal maintenance to reduce recurrence.
4. [End] Infertility → individualized (laparoscopy/ART)
   Infertility-focused → laparoscopy (improves spontaneous conception especially in mild-moderate disease) or assisted reproduction (ART); endometrioma surgery must weigh ovarian reserve (AMH), individualized decision.
5. [End] Refractory/completed childbearing → definitive
   Refractory symptoms, completed childbearing, wants definitive treatment → hysterectomy ± bilateral salpingo-oophorectomy; recurrence risk remains if ovaries are preserved, with full informed consent.

Source guidelines & references

• Endometriosis management (ESHRE 2022; ACOG endometriosis)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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