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.