New SOGC practice guidelines on managing endometriosis offer recommendations on hormone therapy, surgery

The Society for Obstetricians and Gynecologists of Canada (SOGC) has published new clinical practice guidelines for the management of endometriosis. The guidelines include 18 recommendations in the areas of medical and surgical management and healthcare policy, highlighting that treatment for a patient with endometriosis must be individualized for that patient. Physicians should work with the patient and consider their goals, symptoms, the impact of the disease on their lives and the extent of the disease. Management should be long-term and involve a multidisciplinary team to provide lifestyle, medical or surgical interventions that address pain and fertility. Care should be coordinated and physicians should be aware of how surgical management may affect pelvic pain, organ dysfunction and infertility, the guidelines note.Hormone therapyMedical treatment is an effective option for treatment of pain symptoms, but each agent brings unique benefits and adverse events. The guidelines include a summary of recommended medications and details on their use in endometriosis. The guidelines recommend encouraging patients to try hormone therapy for at least three months if side effects are tolerable, before deciding if it is a success or failure. Physicians should counsel patients who are taking hormonal suppression about the potential drop in bone density and suggest ways to maintain bone health. Adolescent patients with presumed or diagnosed endometriosis must consider the impact of hormonal therapy on bone health. The guidelines recommend caution with GnRH agonists in that population.Including hormonal management after conservative surgery (where ovaries and uterus are preserved) could help lower the risk of symptoms returning or disease recurrence. The guidelines recommend offering long-term hormonal therapy to patients who are not planning an immediate pregnancy. Physicians should offer menopausal hormone therapy to patients with surgical or natural menopause. It should contain a progestin to prevent reactivation of endometriosis, the guidelines say.SurgeryPhysicians should assess comorbid chronic pain conditions and other conditions when considering surgical treatment. Patients who wish to preserve fertility may need to consult a fertility specialist.Excision of endometriosis lesions is superior to ablation, the guidelines note. Performing a hysterectomy at the same time reduces the risk of recurrence, re-operation and surgical failure when compared to surgery that spares the uterus, studies suggest. The guidelines provide recommendations on when surgeons can offer a laparoscopic procedure.SOGC recommend physicians use the Endometriosis Fertility Index when counselling patients about fertility following surgery. For patients with ovarian endometriomas, cystectomy is superior to cyst ablation to address pain, fertility and prevent a recurrence, but it is also linked to a drop in anti-Mullerian hormone, a marker of ovarian reserve. Routine bilateral oophorectomy should be avoided except in certain situations, the guidelines recommend.PolicyThe guidelines provide some recommendations for healthcare policy. Firstly, SOGC calls for a provincial and federal system-wide approach to managing endometriosis, with the goal to expand access to advanced imaging and expert healthcare teams. In addition, SOGC wants to see financial support for patients who need to travel to a centre of expertise, especially when they have deep endometriosis and need surgery.The guidelines also address special topics, such as endometriosis and ovarian cancer, and the role of diet and supplements in endometriosis treatment.Dr. Paul Young, Dr. Catherine Allaire and Dr. Mohamed Bedaiwy are the lead authors of the guidelines. They co-authored an overview of the diagnosis and management of endometriosis in CMAJ in 2023. Other authors of the guidelines are Dr. Olga Bougie, Dr. Sari Kives, Dr. Sarah Maheux-Lacroix, Dr. Ally Murji, Dr. Sukhbir Singh and the SOGC endometriosis working group.The guidelines were published in the Journal of Obstetrics and Gynecology Canada.

New SOGC practice guidelines on managing endometriosis offer recommendations on hormone therapy, surgery

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