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Cited by 76Endometriosis Research and TreatmentHealthcare cost, quality, practicesEctopic Pregnancy Diagnosis and Management

Reducing low-value care in endometriosis between limited evidence and unresolved issues: a proposal

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Vercellini, Paolo, Giudice, Linda C., Evers, Johannes L.H., Abrao, Mauricio S.·2015·Human Reproduction
DOI 10.1093/humrep/dev157
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Abstract

Quantification of benefits and harms of medical interventions should be based on high-quality evidence, which is not always the case in the endometriosis field. In many clinical circumstances, healthcare decisions in women with endometriosis are taken based on suboptimal evidence or on evidence of coexistence of benefits and harms that must be balanced. In these conditions, it is important to avoid or reduce the use of low-value care, i.e. interventions with defined harms and uncertain benefits, or whose effectiveness is comparable with less expensive alternatives. In particular, we suggest that: (i) non-surgical diagnosis based on symptoms, physical findings and transvaginal ultrasonography is possible in most women with symptomatic endometriosis. Thus, except in doubtful cases, laparoscopy should be intended for surgical treatment, not for diagnostic purposes: early diagnosis and diagnostic laparoscopy are not synonymous; (ii) future trials on new drugs for endometriosis should address those outcomes that are most important to patients, should be designed as superiority trials and should include a progestin or an estrogen-progestin as a comparator. Moreover, limitation of repetitive surgery for recurrent endometriosis is among the objectives of long-term medical treatment; (iii) indications for surgery should be the result of a balance between demonstrated benefits in terms of fertility enhancement and pain relief, specific risks associated with excision of different types of endometriotic lesions, cost-effectiveness and patient preference after detailed information; (iv) physicians, health professionals and policy makers should discriminate between screening for and diagnosis of endometriosis. Limited peritoneal foci, which are frequently observed also in asymptomatic women, regress or remain stable in about two thirds of cases. Therefore, the theoretical premises for a screening campaign are currently unclear; (v) physicians should develop the ability to effectively communicate quantitative information based on international guidelines and systematic literature reviews. This will assist a woman's understanding of the interaction between the evidence and her priorities, facilitating the transition towards value-based medicine.

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  • Management of endometriosis is often dictated by personal convictions of physicians (and patients) and by local diagnostic-therapeutic paths and expertise (or lack of), rather than by robust evidence derived from adequately designed and conducted pragmatic, randomized, controlled trials (RCT).

    “Management of endometriosis is often dictated by personal convictions of physicians (and patients) and by local diagnostic–therapeutic paths and expertise (or lack of), rather than by robust evidence derived from adequately designed and conducted pragmatic, randomized, controlled trials (RCT) (Vercellini et al., 2015).”

    From When more is not better: 10 ‘don’ts’ in endometriosis management. An ETIC* position statement (2019) · cites this paper as Vercellini et al., 2015

  • The use of low-dose OCs and low-cost progestins for endometriosis management may be termed high-value care.

    “Thus, the use of low-dose OCs and low-cost progestins for endometriosis management may be termed ''high-value care'' (72).”

    From A stepped-care approach to symptomatic endometriosis management: A participatory research initiative (2018) · cites this paper as [72]

  • Vaginal administration has several advantages, such as reduction of daily dosages, continuity of drug release, avoidance of hepatic first-pass effect, and possibility of extending the interval between doses.

    “However, advantages of the vaginal administration are several, such as the reduction of daily dosages, the continuity of drug release, the avoidance of the hepatic first-pass effect, and the possibility of extending the interval between doses, all factors that”

    From Oral and depot progestin therapy for endometriosis: towards a personalized medicine (2017) · cites this paper as [104]

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Authors
Vercellini, P., Giudice, L. C., Evers, J. L. H., & Abrao, M. S.
Affiliations
  • University of Milan (IT)
  • University of California, San Francisco (US)
  • Maastricht University Medical Centre (NL)
Corresponding author
Vercellini, Paolo
ORCID
Venue
Human Reproduction
Publisher
Oxford University Press (OUP)
Published
2015-07-03
Volume
30
Issue
9
Pages
1996-2004
ISSN
  • 0268-1161 (ISSN-L)
  • 1460-2350
DOI
10.1093/humrep/dev157
OpenAlex
W2269509473
Cited by
76
References
14
Citations by year
2026: 5 · 2025: 3 · 2024: 5 · 2023: 2 · 2022: 6 · 2021: 4 · 2020: 6 · 2019: 7 · 2018: 16 · 2017: 11 · 2016: 8 · 2015: 3
FWCI
1.91
Type
journal article
Language
en
Open access
Locations
  • Human Reproduction (publishedVersion)
  • PubMed (publishedVersion)
  • Research Publications (Maastricht University) (submittedVersion, other-oa)
  • eScholarship (California Digital Library) (submittedVersion)
Topics
  • Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
  • Health Sciences › Health Professions › General Health Professions › Healthcare cost, quality, practices
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ectopic Pregnancy Diagnosis and Management
Keywords
endometriosis, low-value care, diagnostic laparoscopy, transvaginal ultrasound, surgical indications, recurrent endometriosis, progestins, estrogen-progestin combination, endometriosis screening, patient communication, value-based medicine, evidence-based medicine, cost-effectiveness
MeSH terms
Endometriosis, Female, Humans, Quality of Health Care, Practice Guidelines as Topic

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