title: Surgery versus hormonal therapy for deep endometriosis: is it a choice of the physician?
abstract: Deep endometriosis, occurring approximately in 1% of women of reproductive age, represents the most severe form of endometriosis. It causes severe pain in the vast majority of affected women and it can affect the bowel and the urinary tract. Hormonal treatment of deep endometriosis with progestins, such as norethindrone acetate or dienogest, or estroprogestins is effective in relieving pain in more than 90% of women at one year follow up. Progestins and estroprogestins can be safely administered in the long-term, may be not expensive and are usually well tolerated. Therefore, they should represent the first-line treatment of deep endometriosis associated pain in women not seeking natural conception. However, hormonal treatment is ineffective or not tolerated in about 30% of women, the most common side effects being erratic bleeding, weight gain, decreased libido and headache. Surgical excision of deep endometriosis is mandatory in presence of symptomatic bowel stenosis, ureteral stenosis with secondary hydronephrosis, and when hormonal treatments fail. Surgical treatment is similarly effective as compared to hormonal treatment in relieving dismenorhea, dyspareunia and dyschezia at one year follow up in more than 90% of women with deep endometriosis. Surgical removal of the nodules may require resection of the bowel, ureter or bladder, with possible severe complications such as rectovaginal or ureterovaginal fistula and anastomotic leakage. A thorough counsel with the patient is necessary in order to pursue a therapeutic plan centered not on the endometriotic lesions, but on the patient's symptoms, priorities and expectations.
authors.affiliation: Department of Obstetrics and Gynecology, Fondazione IRCCS CA' Granda, Ospedale Maggiore Policlinico, University of Milan, Italy; Infertility Unit, Fondazione IRCCS CA' Granda, Ospedale Maggiore Policlinico, University of Milan, Italy. Electronic address: nicola.berlanda@gmail.com.
authors.forename: Nicola
authors.initials: N
authors.lastname: Berlanda
authors.affiliation: Infertility Unit, Fondazione IRCCS CA' Granda, Ospedale Maggiore Policlinico, University of Milan, Italy.
authors.forename: Edgardo
authors.initials: E
authors.lastname: Somigliana
authors.affiliation: Department of Obstetrics and Gynecology, Fondazione IRCCS CA' Granda, Ospedale Maggiore Policlinico, University of Milan, Italy; Infertility Unit, Fondazione IRCCS CA' Granda, Ospedale Maggiore Policlinico, University of Milan, Italy.
authors.forename: Maria Pina
authors.initials: MP
authors.lastname: Frattaruolo
authors.affiliation: Department of Obstetrics and Gynecology, Fondazione IRCCS CA' Granda, Ospedale Maggiore Policlinico, University of Milan, Italy; Infertility Unit, Fondazione IRCCS CA' Granda, Ospedale Maggiore Policlinico, University of Milan, Italy.
authors.forename: Laura
authors.initials: L
authors.lastname: Buggio
authors.affiliation: Department of Obstetrics and Gynecology, Fondazione IRCCS CA' Granda, Ospedale Maggiore Policlinico, University of Milan, Italy; Infertility Unit, Fondazione IRCCS CA' Granda, Ospedale Maggiore Policlinico, University of Milan, Italy.
authors.forename: Dhouha
authors.initials: D
authors.lastname: Dridi
authors.affiliation: Department of Obstetrics and Gynecology, Fondazione IRCCS CA' Granda, Ospedale Maggiore Policlinico, University of Milan, Italy; Infertility Unit, Fondazione IRCCS CA' Granda, Ospedale Maggiore Policlinico, University of Milan, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Vercellini
mesh_terms: D000066491:Clinical Decision-Making; D019468:Disease Management; D004715:Endometriosis / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D005260:Female; D006801:Humans; D007410:Intestinal Diseases / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D010820:Physicians; D016896:Treatment Outcome; D014570:Urologic Diseases / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*
keywords: Deep endometriosis; Hormonal treatment; Laparoscopic surgery; Pelvic pain