Endometriosis · Newport Beach · 2026

Endometriosis Treatment Options
Surgery vs Medication, Staging & Fertility

Understanding the condition. Weighing your options. Building a long-term plan.

Endometriosis affects roughly 1 in 10 women of reproductive age, causing chronic pain, painful periods, and infertility — yet the average diagnosis takes 7 to 10 years. This guide covers what endometriosis is, how it is staged, the full range of medical and surgical treatment options, how it affects fertility, and what long-term management looks like.

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◆ Short Answer

The Canonical Answer

Endometriosis is a chronic condition in which endometrial-like tissue grows outside the uterus, affecting approximately 10 percent of reproductive-age women — roughly 176 million women worldwide ACOG PB #114. Common sites include the ovaries, fallopian tubes, pelvic peritoneum, bowel, and bladder. The disease causes chronic pelvic pain, severe dysmenorrhea, dyspareunia, and infertility, and is classified using the revised ASRM staging system from Stage I (minimal) to Stage IV (severe) — though staging does not correlate reliably with symptom severity ACOG PB #114; ESHRE 2022. First-line medical management includes NSAIDs and hormonal suppression (combined oral contraceptives, progestins, GnRH agonists with add-back therapy, or the GnRH antagonist elagolix). When medical therapy fails, laparoscopic excision is the gold standard for both definitive diagnosis and surgical treatment, with excision preferred over ablation Dunselman 2014; ESHRE 2022. Endometriosis is found in 25 to 50 percent of infertile women, and surgical treatment can improve natural conception rates, particularly in early-stage disease Practice Committee of ASRM. At Broad Medical Group, Dr. Jennifer Broad provides comprehensive endometriosis care from initial evaluation through long-term management for patients in Newport Beach and Orange County.

Medically reviewed by Dr. Jennifer Broad, MD, FACOG Board-Certified Obstetrician-Gynecologist · Newport Beach, CA

Last reviewed: April 2026 Next review: October 2026

Woman consulting with Dr. Broad about endometriosis treatment options at Broad Medical Group in Newport Beach

What Is Endometriosis?

Endometriosis is a chronic, estrogen-dependent condition in which tissue that resembles the endometrium — the lining of the uterus — grows outside the uterus. Unlike normal endometrial tissue, which sheds during menstruation and exits the body, these ectopic implants have no way to exit. They respond to the same hormonal signals as the uterine lining: growing, breaking down, and bleeding with each menstrual cycle. The result is chronic inflammation, scarring, adhesion formation, and pain.

Endometriosis affects approximately 10 percent of women of reproductive age — an estimated 176 million women worldwide. Despite its prevalence, it remains underdiagnosed and poorly understood by many outside of gynecologic specialty care. The exact cause is not definitively established, though the most widely accepted theory involves retrograde menstruation (menstrual blood flowing backward through the fallopian tubes into the pelvic cavity) combined with immune system dysfunction that fails to clear the displaced tissue.

The most common locations for endometriotic implants include:

Ovaries — where endometriomas (“chocolate cysts”) can form
Fallopian tubes — potentially distorting tubal anatomy and impairing fertility
Pelvic peritoneum — the membrane lining the pelvic cavity
Uterosacral ligaments — supporting structures behind the uterus
Bowel — particularly the rectosigmoid colon, causing pain with bowel movements
Bladder — causing urinary symptoms, especially during menstruation

The consequences of untreated or under-treated endometriosis are significant: chronic pelvic pain that can be debilitating, infertility (present in 30–50 percent of affected women), and dense adhesions that can distort pelvic anatomy and impair organ function. Endometriosis is not just “bad periods” — it is a systemic inflammatory condition that affects quality of life, work productivity, relationships, and mental health.

Endometriosis is managed within the broader context of minimally invasive gynecologic surgery when surgical intervention is indicated. At Broad Medical Group, Dr. Broad takes a comprehensive approach to endometriosis that addresses both the pain and the underlying disease process.

Symptoms: More Than Period Pain

The symptoms of endometriosis are variable and often overlap with other conditions, which contributes to the significant diagnostic delay that most patients experience. Some women have severe symptoms with minimal visible disease; others have extensive disease discovered incidentally during surgery for another reason. The hallmark symptoms include:

Dysmenorrhea (painful periods) — severe menstrual cramps that go well beyond what is considered normal. The pain often begins before menstruation starts and persists throughout the period, is poorly responsive to over-the-counter pain medication, and may worsen over time.
Chronic pelvic pain — pain that is not limited to menstruation. Many women with endometriosis experience baseline pelvic pain throughout the cycle, with flares during menstruation.
Dyspareunia (painful intercourse) — particularly deep dyspareunia, often associated with implants on the uterosacral ligaments or in the cul-de-sac (the space behind the uterus).
Painful bowel movements or urination — especially during menstruation, when implants on the bowel or bladder swell and bleed in response to hormonal changes.
Infertility — present in 30 to 50 percent of women with endometriosis. For some women, difficulty conceiving is the presenting complaint that leads to diagnosis.
Fatigue — chronic, often disproportionate to the level of physical activity, likely related to the ongoing systemic inflammatory response.
Bloating — cyclical abdominal distension, sometimes called “endo belly,” that can fluctuate with the menstrual cycle.

The Diagnostic Delay Problem

The average time from symptom onset to endometriosis diagnosis is 7 to 10 years. This delay occurs because painful periods are frequently normalized (“that’s just how periods are”), because there is no reliable non-invasive diagnostic test, and because symptoms overlap with irritable bowel syndrome, interstitial cystitis, and other conditions. Severe menstrual pain that interferes with daily life is not normal — it warrants evaluation, not dismissal.

Patient Tip

Keep a symptom diary. Track your pain (location, severity on a 1–10 scale, timing relative to your cycle), bowel and bladder symptoms, the impact on daily activities, and any relationship to intercourse. A detailed symptom diary is one of the most valuable tools you can bring to your appointment — it helps Dr. Broad identify patterns, assess severity, and make treatment decisions more efficiently than relying on memory alone.

Staging: rASRM Classification

ACOG PB #114 ASRM Classification

Endometriosis is classified using the revised American Society for Reproductive Medicine (rASRM) staging system, which assigns a point score based on the location, extent, and depth of endometriotic implants and adhesions. The staging is determined surgically — it cannot be reliably determined by imaging, physical examination, or symptoms alone. Laparoscopy with visual inspection and ideally histologic confirmation remains the gold standard for definitive diagnosis.

Stage	Classification	Description
Stage I	Minimal	Isolated superficial implants; few small lesions on the peritoneum; no significant adhesions
Stage II	Mild	More implants, deeper than Stage I; some involvement of the cul-de-sac peritoneum; minimal adhesions
Stage III	Moderate	Multiple deep implants; small endometriomas on one or both ovaries; filmy adhesions present
Stage IV	Severe	Large endometriomas; extensive deep infiltrating disease; dense adhesions distorting pelvic anatomy; possible bowel or bladder involvement

Endometriosis rASRM staging classification visual showing Stages I through IV with anatomic illustrations of implant locations and adhesion severity — Revised ASRM classification of endometriosis: Stage I (minimal) through Stage IV (severe). Staging is determined at the time of surgery.

Critical Caveat

Staging does NOT correlate well with symptom severity. A woman with Stage I (minimal) endometriosis can experience debilitating, life-altering pain, while a woman with Stage IV (severe) disease may have relatively mild symptoms or present only with infertility. This is one of the most frustrating aspects of endometriosis — and one of the most important for patients to understand. Your stage describes the anatomic extent of disease. It does not define your pain experience, and it should never be used to dismiss your symptoms.

The rASRM system, while widely used, has known limitations. It does not account well for deeply infiltrating endometriosis (DIE), does not predict pain or fertility outcomes reliably, and has significant inter-observer variability. Newer classification systems — including the ENZIAN classification for deep endometriosis — are increasingly used alongside rASRM to provide a more complete picture of disease extent. Despite these limitations, the rASRM system remains the most commonly referenced staging system in clinical practice and research.

Medical Management

Medical management is the first-line approach for endometriosis-related pain in most patients. The goals are to suppress the hormonal stimulation that drives endometriotic tissue growth, reduce inflammation, and manage pain. It is important to understand upfront: medical management suppresses endometriosis but does not cure it. Symptoms typically recur when treatment is discontinued, because the underlying implants remain in place.

Pain Management: NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen are the foundation of symptomatic pain relief. They work by inhibiting prostaglandin synthesis, which drives both inflammation and uterine cramping. NSAIDs are most effective when taken before the onset of pain (i.e., starting 1–2 days before expected menstruation) rather than waiting for pain to become established. They are typically used alongside hormonal suppression, not as standalone therapy for confirmed endometriosis.

Hormonal Suppression Options

The principle behind hormonal therapy for endometriosis is straightforward: endometriotic tissue is estrogen-dependent. Reducing estrogen stimulation reduces the activity and growth of implants. Several hormonal approaches are available, and the choice depends on the patient’s symptoms, fertility plans, side effect tolerance, and response to prior treatment.

Combined oral contraceptives (COCs) are often the first hormonal agent tried, particularly in younger patients or those who also need contraception. Continuous use (skipping the placebo week to avoid withdrawal bleeding) is preferred over cyclic use for endometriosis management, as it provides more consistent suppression and eliminates the menstrual flare that many patients experience.

Progestins provide effective suppression for many patients. Options include norethindrone acetate (oral, 5 mg daily), dienogest (2 mg daily — specifically studied and approved for endometriosis in many countries), the levonorgestrel intrauterine device (Mirena), and medroxyprogesterone acetate (Depo-Provera). Progestins work by decidualizing and atrophying endometriotic tissue, reducing inflammation, and often reducing or eliminating menstruation.

GnRH agonists such as leuprolide (Lupron) create a temporary menopausal state by suppressing the hypothalamic-pituitary-ovarian axis after an initial “flare” phase. They are highly effective for pain control but cause significant menopausal side effects (hot flashes, vaginal dryness, bone density loss). For this reason, GnRH agonists are used with add-back therapy — low-dose norethindrone with or without conjugated estrogen — to mitigate side effects while maintaining therapeutic benefit. Use is generally limited to 6 to 12 months due to the risk of bone density reduction.

GnRH antagonists represent a newer class. Elagolix (Orilissa) is FDA-approved specifically for the management of endometriosis pain. Unlike GnRH agonists, elagolix is an oral medication that provides dose-dependent estrogen suppression without the initial flare phase. At lower doses (150 mg once daily), it produces partial estrogen suppression and can be used for up to 24 months; at higher doses (200 mg twice daily, with add-back), the treatment duration is limited to 6 months. Elagolix offers a more nuanced approach to estrogen management than the all-or-nothing suppression of GnRH agonists.

ACOG Guideline

ACOG Practice Bulletin #114 recommends empiric treatment with hormonal therapy for women with clinically suspected endometriosis without requiring surgical confirmation first. If a patient has characteristic symptoms and responds to hormonal suppression, this supports the clinical diagnosis and surgery can be deferred. Surgery is pursued when medical management fails, when histologic diagnosis is needed, or when fertility optimization requires it.

Limitations of Medical Management

Medical therapy is effective for symptom control in many patients, but it has important limitations that should be understood:

It suppresses but does not eradicate endometriotic tissue — the disease is still there when medication is stopped.
Symptoms typically recur after discontinuation, often within months.
Medical therapy does not improve fertility — in fact, hormonal suppression prevents conception while in use. Medical management is for pain, not for fertility.
Long-term use of some agents (particularly GnRH agonists) has side effect limitations including bone density loss and menopausal symptoms.
Some patients do not respond adequately to any available medical therapy, necessitating surgical intervention.

Surgical Management

Surgery plays a dual role in endometriosis: it is both the gold standard for definitive diagnosis (via visual inspection and histologic confirmation) and the primary treatment for disease that has failed medical management. Laparoscopy is the preferred surgical approach, offering the advantages of minimally invasive technique including shorter recovery, reduced adhesion formation, and excellent visualization of the pelvic anatomy. For details on the specific surgical techniques, instrumentation, and the laparoscopic approach used at Broad Medical Group, see our minimally invasive gynecologic surgery overview.

Excision vs Ablation

Two primary techniques exist for treating endometriotic implants at the time of surgery:

Excision (resection) — the implant is cut out completely, including the tissue beneath the surface. This is the preferred approach because it removes the full depth of the lesion, provides tissue for histologic confirmation, and has lower recurrence rates compared to ablation.
Ablation (cauterization) — the surface of the implant is destroyed using heat, laser, or electrical energy. This technique treats only the visible surface and may leave deeper disease behind, particularly with deeply infiltrating endometriosis.

The evidence supports excision as superior to ablation for both pain relief and recurrence reduction, and major guidelines including ESHRE recommend excision as the preferred surgical technique when feasible.

When Surgery Is Indicated

Surgery is not the first step for most patients with suspected endometriosis. However, it is indicated in several important scenarios:

Failed medical management — when hormonal therapy and NSAIDs have not adequately controlled symptoms.
Desire for histologic diagnosis — some patients and clinicians prefer surgical confirmation, particularly when the clinical picture is ambiguous or treatment decisions depend on confirmed diagnosis.
Fertility optimization — when endometriosis is suspected as a contributor to infertility and surgical treatment may improve natural conception rates (see fertility section below).
Endometriomas ≥4 cm — ovarian endometriomas above this threshold are unlikely to resolve with medical therapy and can compromise ovarian tissue if left untreated.
Concern for malignancy — ovarian masses with atypical imaging features require surgical evaluation to exclude ovarian cancer, although malignant transformation of endometriosis is rare.

Hysterectomy: When Other Options Have Been Exhausted

Hysterectomy with bilateral salpingo-oophorectomy (removal of the uterus, fallopian tubes, and both ovaries) is considered the most definitive surgical treatment for endometriosis. By removing the ovaries, the estrogen source that drives endometriotic tissue is eliminated. However, several important caveats apply:

Hysterectomy is not first-line treatment. It is reserved for women who have completed childbearing, have failed other medical and surgical options, and have a thorough understanding of the irreversible consequences, including surgical menopause if the ovaries are removed.
Even hysterectomy with bilateral oophorectomy does not guarantee zero recurrence — residual endometriotic implants can be stimulated by adrenal estrogen or exogenous hormone replacement therapy, though the risk is low.
In some cases, hysterectomy with ovarian preservation may be appropriate, particularly in younger women. This preserves natural hormone production but carries a higher recurrence risk than bilateral oophorectomy.

Endometriosis treatment algorithm flowchart showing decision pathway from initial symptoms through medical management, surgical options, and fertility considerations — Endometriosis treatment decision algorithm. Medical management is first-line for pain; surgery is indicated for failed medical therapy, fertility optimization, or diagnostic confirmation.

Endometriosis and Fertility

Endometriosis is found in 25 to 50 percent of women who are evaluated for infertility, making it one of the most common identifiable causes of difficulty conceiving. The relationship between endometriosis and infertility is complex, operating through several mechanisms:

Anatomic distortion from adhesions — adhesions can block or kink the fallopian tubes, preventing egg pickup and transport. Ovarian adhesions can prevent ovulation or impair the release of the egg into the tube.
Endometriomas and ovarian reserve — endometriomas (ovarian cysts filled with old blood) damage the surrounding ovarian cortex, reducing the number of available eggs. Both the presence of the endometrioma and its surgical removal can impact ovarian reserve, requiring careful treatment decisions.
Inflammatory peritoneal environment — the inflammatory milieu created by endometriosis alters the peritoneal fluid composition, which may impair egg quality, sperm function, fertilization, and embryo implantation even in the absence of visible anatomic distortion.

Surgical Treatment and Natural Conception

For women with Stage I and Stage II endometriosis and infertility, surgical excision or ablation of implants has been shown to improve natural conception rates. The landmark Canadian trial by Marcoux et al. demonstrated a significant improvement in fecundity following laparoscopic treatment of minimal and mild endometriosis compared to diagnostic laparoscopy alone. For early-stage disease, surgery is a reasonable first step before proceeding to assisted reproductive technologies.

For Stage III and Stage IV endometriosis with infertility, the benefit of surgery on natural conception is less clearly established, and in vitro fertilization (IVF) is often recommended after surgical optimization. Surgery in these cases focuses on restoring anatomy, removing endometriomas, and creating the best possible environment for IVF success.

Endometrioma Management: Cystectomy vs Drainage

When ovarian endometriomas are present, the surgical approach matters for fertility preservation:

Cystectomy (excision of the cyst wall) has lower recurrence rates and better long-term outcomes compared to simple drainage and ablation. However, cystectomy removes some healthy ovarian tissue along with the cyst wall, which can reduce ovarian reserve (lower AMH levels and antral follicle count).
Drainage alone (with or without ablation of the cyst lining) preserves more ovarian tissue but has significantly higher recurrence rates — up to 50 percent or more.

The decision between these approaches requires a careful balance between recurrence risk and ovarian reserve preservation. In women planning IVF, the decision to operate on endometriomas must weigh the potential benefit of cyst removal against the risk of further compromising an already-impacted ovarian reserve. For bilateral endometriomas, particular caution is warranted. These decisions are individualized based on age, AMH levels, symptoms, cyst size, and reproductive plans.

Living with Endometriosis: Long-Term Management

Endometriosis is a chronic condition. Unlike a discrete problem that is fixed with a single surgery or course of medication, endometriosis requires ongoing management, monitoring, and adaptation of treatment over years and even decades. Understanding this reality is essential for setting appropriate expectations and building a sustainable treatment plan.

Recurrence After Surgery

Even after thorough surgical excision, endometriosis recurrence rates are 20 to 40 percent within five years. This does not mean surgery has failed — it means the condition has an inherent tendency to recur as long as the hormonal environment that drives it persists. Factors that influence recurrence include the completeness of initial excision, disease severity, patient age, and whether postoperative hormonal suppression is used.

Postoperative Hormonal Suppression

To reduce the risk of recurrence after surgery, postoperative hormonal suppression is recommended for women who are not trying to conceive. Options include continuous combined oral contraceptives, progestins (oral or the levonorgestrel IUD), or other hormonal agents used for primary medical management. The levonorgestrel IUD (Mirena) has particularly strong evidence for reducing endometrioma recurrence and dysmenorrhea after surgical treatment. The duration of postoperative hormonal therapy is individualized — for many women, it continues until a desired pregnancy or menopause.

The Multimodal Approach

The most effective long-term management of endometriosis combines multiple strategies:

Surgical excision to debulk or remove visible disease
Hormonal suppression to reduce the hormonal drive for recurrence
Pain management — NSAIDs, pelvic floor physical therapy, neuromodulating agents for chronic pain syndromes that develop secondary to endometriosis (such as central sensitization)
Psychological support — chronic pain conditions have significant impacts on mental health, relationships, and quality of life. Cognitive behavioral therapy and support groups can be valuable adjuncts.
Regular follow-up with a physician who understands the chronic nature of endometriosis and does not treat each visit as an isolated encounter. Continuity of care matters.

At Broad Medical Group, Dr. Broad approaches endometriosis as a long-term partnership with each patient — not a single consultation that ends with a prescription. Treatment plans evolve as symptoms change, as reproductive goals shift, and as new evidence and treatment options emerge.

When to Call Immediately

Contact Dr. Broad’s office or go to Hoag Hospital emergency department if you experience any of the following:

Sudden, severe pelvic or abdominal pain that is different from your usual endometriosis pain — particularly sharp, one-sided pain that may indicate ovarian torsion (twisting of the ovary), which is a surgical emergency and is more likely in women with large endometriomas
Fever with pelvic pain — may indicate infection, especially if you have recently undergone a procedure
Dizziness, lightheadedness, or fainting with abdominal pain — may indicate a ruptured endometrioma with significant bleeding
Inability to eat, drink, or have bowel movements with abdominal distension — may indicate bowel obstruction from endometriosis-related adhesions

If you are experiencing a medical emergency, call 911.

Key Takeaways

Endometriosis affects ~10% of reproductive-age women — endometrial-like tissue grows outside the uterus, causing chronic pain, dysmenorrhea, dyspareunia, and infertility.
Diagnosis is delayed an average of 7–10 years because symptoms are often normalized. Severe menstrual pain that interferes with daily life is not normal.
Staging (rASRM I–IV) does not correlate with symptom severity — a woman with Stage I can have more pain than Stage IV. Staging describes anatomic extent, not pain.
First-line medical management includes NSAIDs plus hormonal suppression (continuous COCs, progestins, GnRH agonists with add-back, or elagolix). Medical therapy suppresses but does not cure.
Laparoscopic excision is the gold standard surgical treatment — excision preferred over ablation. Surgery is indicated for failed medical therapy, fertility optimization, endometriomas ≥4 cm, or diagnostic confirmation.
Endometriosis is found in 25–50% of infertile women — surgical treatment can improve natural conception in early-stage disease; IVF is recommended for moderate-to-severe disease after surgical optimization.
Long-term management is multimodal — recurrence rates are 20–40% within 5 years after surgery. Postoperative hormonal suppression, pain management, and continuity of care are essential.

References & Clinical Sources

American College of Obstetricians and Gynecologists. Practice Bulletin No. 114: Management of Endometriosis. Obstetrics & Gynecology, 116(1), 223–236. 2010. Reaffirmed 2022.
European Society of Human Reproduction and Embryology (ESHRE). Endometriosis Guideline. 2022.
Dunselman GA, Vermeulen N, Briner C, et al. ESHRE guideline: management of women with endometriosis. Human Reproduction, 29(3), 400–412. 2014.
Vercellini P, Vigano P, Somigliana E, Fedele L. Endometriosis: pathogenesis and treatment. Nature Reviews Endocrinology, 10(5), 261–275. 2014.
Practice Committee of the American Society for Reproductive Medicine. Endometriosis and infertility: a committee opinion. Fertility and Sterility, 98(3), 591–598. 2012.
Chapron C, Marcellin L, Borghese B, Santulli P. Rethinking mechanisms, diagnosis and management of endometriosis. Nature Reviews Endocrinology, 15(11), 666–682. 2019.
Marcoux S, Maheux R, Bérubé S; Canadian Collaborative Group on Endometriosis. Laparoscopic surgery in infertile women with minimal or mild endometriosis. New England Journal of Medicine, 337(4), 217–222. 1997.

Related Resources

Endometriosis. Understood and Treated.

Living with endometriosis or suspect you may have it? Dr. Broad provides comprehensive endometriosis care — from initial evaluation and diagnosis through medical management, surgical treatment, and long-term follow-up — for patients in Newport Beach and Orange County.

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Broad Medical Group — Newport Beach, California

Medical Disclaimer: This content is for educational purposes only and does not constitute medical advice, diagnosis, or treatment. Consult Dr. Jennifer Broad or your healthcare provider for guidance specific to your situation. Current as of April 2026. If you are experiencing a medical emergency, call 911 immediately.