Journal of the European Society for Gynaecological Endoscopy


Reconsidering evidence-based management of endometriosis

P.R. Koninckx1,2, A. Ussia3, S. Alsuwaidi1, B. Amro1, J. Keckstein4, L. Adamyan5, J. Donnez6, M.C. Martin7, A. Wattiez1,8

1 Latifa Hospital, Dpt OBGYN, Dubai, United Arab Emirates
2 Prof Emeritus OBGYN KULeuven Belgium, University of Oxford, and Hon Consultant, UK, University; Cattolica, Roma, Italy and Moscow State Univ, Russia
3 Consultant Università Cattolica, Dpt OBGYN Roma Italy
4 Endometriosis Centre, County Hospital Villach, Austria and University Ulm, Dpt OBGYN, Ulm, Germany
5 Department of Operative Gynecology, Federal State Budget Institution V. I. Kulakov Research Centre for Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia; and Department of Reproductive Medicine and Surgery, Moscow State University of Medicine and Dentistry, Moscow, Russia
6 Prof emeritus Catholic University of Louvain, Dpt OBGYN, Brussels, Belgium
7 Prof Emeritus, Dpt OBGYN, University of Tennessee Health Science Centre, Memphis Tennessee, USA; Institutional Review Board, Virginia Commonwealth University, Richmond, Virginia, USA
8 Prof Department of obstetrics and gynaecology, University of Strasbourg, France


evidence, statistical inference, Bayesian, endometriosis, evidence-based medicine

Published online: Sep 30 2022


Background: Without an adequate animal model permitting experiments the pathophysiology of endometriosis remains unclear and without a non-invasive diagnosis, information is limited to symptomatic women. Lesions are macroscopically and biochemically variable. Hormonal medical therapy cannot be blinded since recognised by the patient and the evidence of extensive surgery is limited because of the combination of low numbers of interventions of variable difficulty with variable surgical skills. Experience is spread among specialists in imaging, medical therapy, infertility, pain and surgery. In addition, the limitations of traditional statistics and p-values to interpret results and the complementarity of Bayesian inference should be realised.

Objectives: To review and discuss evidence in endometriosis management

Materials and Methods: A PubMed search for blinded randomised controlled trials in endometriosis.

Results: Good-quality evidence is limited in endometriosis.

Conclusions: Clinical experience remains undervalued especially for surgery.

What is new? Evidence-based medicine should integrate traditional statistical analysis and the limitations of P-values, with the complementary Bayesian inference which is predictive and sequential and more like clinical medicine. Since clinical experience is important for grading evidence, specific experience in the different disciplines of endometriosis should be used to judge trial designs and results. Finally, clinical medicine can be considered as a series of experiments controlled by the outcome. Therefore, the clinical opinion of many has more value than an opinion.