Except when surgery is the only option because of organ damage, the presence of suspicious lesions, or the desire to conceive, women with endometriosis-associated pain often face a choice between medical and surgical treatment. In theory, the description of the potential benefits and potential harms of the two alternatives should be standardized, unbiased, and based on strong evidence, enabling the patient to make an informed decision. However, doctor’s opinion, intellectual competing interests, local availability of specific services and (mis)information obtained from social media, and online support groups can influence the type of advice given and affect patients’ choices. This is compounded by the paucity of robust data from randomized controlled trials, and the anxiety of distressed women who are eager to do anything to alleviate their disabling symptoms. Vulnerable patients are more likely to accept the suggestions of their healthcare provider, which can lead to unbalanced and physician-centred decisions, whether in favour of either medical or surgical treatment. In general, treatments should be symptom-orientated rather than lesion-orientated. Medical and surgical modalities appear to be similarly effective in reducing pain symptoms, with medications generally more successful for severe dysmenorrhoea and surgery more successful for severe deep dyspareunia caused by fibrotic lesions infiltrating the posterior compartment. Oestrogen–progestogen combinations and progestogen monotherapies are generally safe and well tolerated, provided there are no major contraindications. About three-quarters of patients with superficial peritoneal and ovarian endometriosis and two-thirds of those with infiltrating fibrotic lesions are ultimately satisfied with their medical treatment although the remainder may experience side effects, which may result in non-compliance. Surgery for superficial and ovarian endometriosis is usually safe. When fibrotic infiltrating lesions are present, morbidity varies greatly depending on the skill of the individual surgeon, the need for advanced procedures, such as bowel resection and ureteral reimplantation, and the availability of expert colorectal surgeons and urologists working together in a multidisciplinary approach. The generalizability of published results is adequate for medical treatment but very limited for surgery. Moreover, on the one hand, hormonal drugs induce disease remission but do not cure endometriosis, and symptom relapse is expected when the drugs are discontinued; on the other hand, the same drugs should be used after lesion excision, which also does not cure endometriosis, to prevent an overall cumulative symptom and lesion recurrence rate of 10% per postoperative year. Therefore, the real choice may not be between medical treatment and surgery, but between medical treatment alone and surgery plus postoperative medical treatment. The experience of pain in women with endometriosis is a complex phenomenon that is not exclusively based on nociception, although the role of peripheral and central sensitization is not fully understood. In addition, trauma, and especially sexual trauma, and pelvic floor disorders can cause or contribute to symptoms in many individuals with chronic pelvic pain, and healthcare providers should never take for granted that diagnosed or suspected endometriosis is always the real, or the sole, origin of the referred complaints. Alternative treatment modalities are available that can help address most of the additional causes contributing to symptoms. Pain management in women with endometriosis may be more than a choice between medical and surgical treatment and may require comprehensive care by a multidisciplinary team including psychologists, sexologists, physiotherapists, dieticians, and pain therapists. An often missing factor in successful treatment is empathy on the part of healthcare providers. Being heard and understood, receiving simple and clear explanations and honest communication about uncertainties, being invited to share medical decisions after receiving detailed and impartial information, and being reassured that a team member will be available should a major problem arise, can greatly increase trust in doctors and transform a lonely and frustrating experience into a guided and supported journey, during which coping with this chronic disease is gradually learned and eventually accepted. Within this broader scenario, patient-centred medicine is the priority, and whether or when to resort to surgery or choose the medical option remains the prerogative of each individual woman.

中文翻译：

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对症状性子宫内膜异位症进行综合治疗：超越药物治疗与手术治疗的二分法

除非由于器官损伤、存在可疑病变或想要怀孕而手术是唯一的选择，否则患有子宫内膜异位症相关疼痛的女性通常面临药物治疗和手术治疗之间的选择。理论上，对两种替代方案的潜在益处和潜在危害的描述应该是标准化的、公正的，并基于强有力的证据，使患者能够做出明智的决定。然而，医生的意见、智力竞争利益、当地特定服务的可用性以及从社交媒体和在线支持小组获得的（错误）信息可能会影响所提供建议的类型并影响患者的选择。由于缺乏来自随机对照试验的可靠数据，以及渴望采取任何措施来减轻其残疾症状的痛苦女性的焦虑，加剧了这一问题。弱势患者更有可能接受医疗保健提供者的建议，这可能会导致不平衡和以医生为中心的决定，无论是赞成药物治疗还是手术治疗。一般来说，治疗应该以症状为导向，而不是以病变为导向。药物和手术方式似乎在减轻疼痛症状方面同样有效，药物通常对严重痛经更有效，而手术对由纤维化病变浸润后室引起的严重深度性交痛更有效。只要没有重大禁忌症，雌激素-孕激素联合疗法和孕激素单一疗法通常是安全且耐受性良好的。约四分之三的浅表腹膜和卵巢子宫内膜异位症患者以及三分之二的浸润性纤维化病变患者最终对治疗感到满意，尽管其余患者可能会出现副作用，从而导致不依从治疗。浅表子宫内膜异位症和卵巢子宫内膜异位症的手术通常是安全的。当存在纤维化浸润病变时，发病率差异很大，具体取决于外科医生个人的技能、肠切除和输尿管再植入等先进手术的需要，以及结直肠外科医生和泌尿科医生以多学科方法合作的情况。已发表结果的普遍性对于医疗来说是足够的，但对于手术来说非常有限。此外，一方面，激素药物可以使疾病缓解，但不能治愈子宫内膜异位症，停药后症状会复发；另一方面，病灶切除后应使用相同的药物，这也不能治愈子宫内膜异位症，以防止总体累积症状和术后每年10%的病灶复发率。因此，真正的选择可能不是在药物治疗和手术之间，而是在单纯药物治疗和手术加术后药物治疗之间。子宫内膜异位症女性的疼痛体验是一种复杂的现象，并不完全基于伤害感受，尽管外周和中枢敏化的作用尚未完全了解。此外，创伤，尤其是性创伤和盆底疾病可能会导致或加剧许多慢性盆腔疼痛患者的症状，医疗保健提供者不应理所当然地认为诊断或怀疑的子宫内膜异位症始终是真实的或唯一的。所转述投诉的来源。有替代治疗方式可以帮助解决大多数导致症状的其他原因。子宫内膜异位症女性的疼痛管理可能不仅仅是药物和手术治疗之间的选择，可能需要包括心理学家、性学家、物理治疗师、营养师和疼痛治疗师在内的多学科团队的全面护理。成功治疗中经常缺失的一个因素是医疗保健提供者的同理心。被倾听和理解、接受简单明了的解释以及关于不确定性的诚实沟通、在收到详细和公正的信息后被邀请分享医疗决定、并确信团队成员会在出现重大问题时随时提供帮助，这些都可以大大增加对团队的信任。医生将孤独和沮丧的经历转变为引导和支持的旅程，在此过程中，人们逐渐学会并最终接受如何应对这种慢性疾病。在这种更广泛的情况下，以患者为中心的医学是首要任务，是否或何时诉诸手术或选择医疗选择仍然是每个女性的特权。可以极大地增加对医生的信任，并将孤独和沮丧的经历转变为引导和支持的旅程，在此过程中逐渐学会并最终接受如何应对这种慢性疾病。在这种更广泛的情况下，以患者为中心的医学是首要任务，是否或何时诉诸手术或选择医疗选择仍然是每个女性的特权。可以极大地增加对医生的信任，并将孤独和沮丧的经历转变为引导和支持的旅程，在此过程中逐渐学会并最终接受如何应对这种慢性疾病。在这种更广泛的情况下，以患者为中心的医学是首要任务，是否或何时诉诸手术或选择医疗选择仍然是每个女性的特权。