New principles in the management of endometriosis.

The current management of endometriosis includes expectant, medical, surgical and combined therapies and the selection is based on the staging of the disease proposed by the American Fertility Society (AFS). This approach, however, has proven to be inadequate for the selection of medical treatment. Peritoneal endometriosis represents a range of lesions of different activity and stage of evolution. Surgical resection carries a risk of adhesion formation. Two to three months of medical therapy can induce inactivation and regression of active lesions. These factors should be taken into account in the selection of therapy. Ovarian endometrial cysts are indications for reconstructive surgery. The extent of adhesions and fibrosis, rather than the size of the cyst, determine the surgical outcome. The invaginated cortex explains the frequent association with lutein cysts. Large cysts can be conservatively treated at laparoscopy in a three-step procedure with a 3-month medical therapy between the first and second laparoscopy. Deep nodular endometriosis presents different lesions varying from fibrosis to adenomyosis. The effect of a therapeutic medical trial can be evaluated within 2 months. Different modalities are available for long-term medical therapy. Surgical resection is the treatment of choice for the adenomyosis type.