Indications for Laparoscopy
Diagnostic and operative laparoscopy should be considered in those women with pelvic pain which has not responded after 3 months of nonsteroidal antiinflammatory drugs (NSAIDs), and/or 3 months of oral contraceptives. In addition, those patients with symptoms mentioned above coupled with the finding of culdesac nodularity on pelvic examination should undergo laparoscopic evaluation and treatment since most will have more advanced endometriosis.

Patients under 35 years of age with infertility of more than one year duration with clinical findings consistent with endometriosis should undergo laparoscopy, regardless of symptoms (remember, around 30% of patients with endometriosis have no symptoms). Similar patients over 35 should undergo laparoscopy after 6 months of infertility, since their "ovarian reserve" may not allow more prolonged "expectant" therapy.

More advanced stages of endometriosis (AFS stage III - IV) should always be suspected in premenopausal patients undergoing laparoscopic evaluation of an ovarian mass. In these clinical circumstances, the operating gynecologist should always be skilled in the laparoscopic treatment of advanced endometriosis, since some of these patients will require such surgical therapy.

If laparoscopic surgery is appropriately performed, it is extremely uncommon for endometriotic lesions to recur within a few months. Using excisional techiques, individual endometriotic implants or nodules are carefully, precisely, and completely removed. These implants will not recur or "come back". New implants may grow in the same anatomic area, but this normally requires significant passage of time. Repeated laparoscopic surgeries to treat endometriosis that seems to "come back" every few months almost always reflects incomplete removal or inadequate surgical treatment.

Agressive surgical therapy for advanced endometriosis in the infertile patient virtually always results in adhesion formation (adhesions are most often present in these patients when the endometriosis is discovered). Repeat laparoscopic surgery (usually within 6 weeks) for the purpose of treating these adhesions is sometimes recommended in the younger infertile patient.

Laparotomy is an appropriate approach only when the surgeon does not have the requisite skills or facilities to perform these very complex and tedious surgical procedures via laparoscopy.

Management Options
In order to develop a long term treatment plan for the patient with endometriosis, the gynecologist must carefully and thoroughly evaluate many factors, including:

• the patient's age
• severity of symptoms
• type and extent of disease
• plans for future pregnancy (including her timeframe for attaining pregnancy)
• physical findings
• lifestyle of the patient

She may be a teenager desiring future pregnancy, a woman planning immediate pregnancy, or a woman who has completed her childbearing and/or does not desire future pregnancy. Patients may present with undiagnosed pelvic pain or pain associated with recurrence of endometriosis after prior treatment. Often these patients have undergone several laparoscopic procedures already.

Several medical management options are available. These include no treatment, and/or limited use of analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs). Medical therapy can also consist of oral contraceptives, progestins, or GnRH agonists (lupron). Oral contraceptives can be given cyclically (the patient has a monthly menses) or continuously (the patient has no menses during treatment). Progestins (Provera 10 mgmevery day) or depoprovera injections will incompletely suppress ovarian function, but can be associated with breakthrough bleeding; they may be useful in a few women who cannot tolerate oral contraceptives.

GnRH agonists (lupron) are synthetic decapeptides. Nafarelin acetate (Synarel) 200 Fgnasal spray used twice a day, is a superactive, hydrophobic stimulatory analog of GnRH that is 200 times more potent than naturally occurring GnRH, and is delivered in a meterednasal spray pump. Leuprolide acetate (Lupron Depot) is usually given as a single monthly 3.75 mgm intramuscular injection. The GnRH agonists initially stimulate the pituitary gland to release follicle stimulating hormone (FSH) and luteinizing hormone (LH). As a consequece, blood estrogen levels initially rise, then fall to menopausal levels within a few days. After 7 to 10 days, these drugs produce a menopausal state which is fully reversible. This produces amenorrhea (no menses), which permits regression of endometriosis and relief of symptoms. The GnRH agonists do not have any known direct effects on the ovary.

In the infertile patient, laparoscopic therapy is almost always conservative, consisting of excision, laser vaporization, or electrosurgical desiccation of endometriosis. Every attempt should be made to conserve as much ovarian tissue as possible in these patients.

Patients who have completed childbearing often undergo more radical laparoscopic therapy, including hysterectomy and/or bilateral salpingo-oophorectomy. Simple removal of the uterus and\or ovaries is not necessarily the appropriate operation, however. If the surgeon removes the uterus and ovaries, but leaves implants of endometriosis behind, the patient may continue to have pain very similar to that she experienced prior to the operation. Remember, symptoms may be as much a result of the implants of endometriosis as from the uterus or ovaries.

Adequate laparoscopic treatment of endometriosis requires a surgeon who is familiar with the pathophysiology of endometriosis and its various appearances. They must posess the skills to treat implants on or near vital structures in the pelvis, and have access to the proper laparoscopic equipment necessary to perform these procedures.

Medical vs Surgical Therapy (infertilepatient)
In the infertile patient, some studies indicate that medical and surgical treatments sometimes have the same results. However, laparoscopic surgical treatment appropriately completed at the time of diagnosis has a distinct advantage over medical therapy. All medical therapy regimens require at least six months of therapy before the patient can even begin her attempts at pregnancy. On the other hand, patients fully treated at their initial laparoscopy begin attempts at pregnancy within 3 weeks, a significant savings in time over medical management. In addition, patients undergoing medical therapy must "enjoy" the side effects of their treatment for at least 6 months. Surgically treated patients recover from their laparoscopic procedure in 1-2 weeks.

Laparoscopic treatment of endometriosis may sometimes be combined with medical therapy involving progesterone or GnRH agonists. This combination is most often used in the patient who is not currently attempting pregnancy, but plans to do so in the next 1 to 2 years. Medical therapy is used in these patients (after laparoscopic treatment) in the hope that it may inhibit growth of new endometriotic implants before the patient begins her attempts at pregnancy.

Some patients will be placed on medical therapy preoperatively to suppress ovulatory function so that "functional" ovarian cysts will not be confused with endometriosis. Potential disadvantages of preoperative medical treatment include the changed appearance of endometriosis, which might make it more difficult to diagnose; drug cost and side effects; delay of diagnosis; and delay in attempting pregnancy.

Postoperative medical treatment may be indicated if the disease has not been completely resected, for treatment of microscopic or metastatic disease, or for treatment of pain unrelieved by surgery. Preoperative or postoperative treatment is usually given for 2 to 6 months.

Many patients prefer no treatment, or medical treatment before surgery. However, surgery is often the most appropriate approach. Most patients prefer to retain as many of their reproductive organs as possible, but for some oophorectomy and/or hysterectomy is a better option. Laparoscopy is generally the preferred surgical approach, but laparotomymay be appropriate for rare cases, especially those requiring bowel resection.

It is critical that physicians recognize the degree to which endometriosis can physically and emotionally disrupt patients' lives. Patients can better understand the condition, its implications, and appropriate treatment through information obtained from organizations such as the Endometriosis Association, Resolve, and the American Society for Reproductive Medicine. Personal or group counseling may also be helpful, especially for the patient with chronic pain. Some patients may seek nontraditional and unproven approaches to treatment such as acupuncture, special diets, and/or exercise. Management in these chronic, complex situations should focus on relief or alleviation of symptoms. A comprehensive evaluation of gastrointestinal, genitourinary, musculoskeletal, neurologic,and psychologic systems may be indicated. Referral to a pain clinic may be helpful and involve recognizing that a complete cure can often only be achieved by total hysterectomyand bilateral salpingo-oophorectomy. Further treatment including biofeedback strategies, nerve blocks, psychotherapy, or other pain management techniques.

Our most important rule: A comprehensive long-range treatment approach must be individualized for each patient.