The ESHRE 2022 Endometriosis Guideline: What Changed and What It Means

The 2022 ESHRE Endometriosis Guideline reorganised first-line care around three shifts: diagnosis no longer requires laparoscopy — clinical assessment plus expert imaging can establish it in most cases; medical therapy is first-line for pain in most patients; and surgical and fertility decisions must be individualised, with explicit attention to preserving ovarian reserve and avoiding unnecessary repeat surgery. For patients, the practical message is that good endometriosis care now starts earlier, less invasively, and with a clearer plan.

1. Diagnosis no longer starts in the operating theatre

For decades, laparoscopy was treated as the only way to be “sure” of endometriosis — a stance that added years of delay and an operation before any treatment could begin. ESHRE 2022 explicitly moved away from this. A careful history, examination and expert imaging (transvaginal ultrasound, with MRI where needed) can establish the diagnosis in most women, and treatment can begin on that basis. Importantly, the guideline also makes clear that normal imaging does not exclude endometriosis — superficial disease is often invisible on scans — so empirical medical treatment remains appropriate when the clinical picture fits. Diagnostic laparoscopy is now reserved for situations where the result will genuinely change the plan. See how expert endometriosis ultrasound works →

2. Medical therapy is first-line for pain

For pain, the guideline positions hormonal medical therapy as the first step in most patients: combined hormonal contraceptives or progestins such as dienogest, used continuously to suppress cyclical activity. Where these are insufficient, GnRH analogues with hormonal “add-back” are a second-line option that protects bone and reduces menopausal side-effects. Anti-inflammatories help symptomatically. The deliberate emphasis is on controlling disease activity over the long term rather than reaching for surgery early — while recognising that medication suppresses, but does not cure, the disease, and that choices must fit a woman’s fertility plans and tolerance.

3. Surgery is selective — and ovarian reserve is protected

Surgery keeps an important role — for pain that fails medical therapy, for deep disease affecting bowel or bladder, and in selected fertility situations — but ESHRE 2022 frames it as a considered decision, not a default. The guideline is particularly careful about ovarian endometriomas (chocolate cysts): removing them measurably reduces ovarian reserve, so the decision to operate must weigh symptom relief and cancer-risk concerns against the cost to future egg numbers, with AMH counselling beforehand. Repeat surgery is discouraged where it threatens the ovary without a clear benefit. This is the heart of the modern philosophy: do the right operation once, in the right hands, rather than several diminishing ones.

4. Fertility decisions are integrated, not sequential

The fertility chapter is where the guideline is most nuanced. Hormonal medical therapy does not improve natural fertility and only delays conception, so it is not used for that purpose. Surgery to remove an endometrioma before IVF is not routinely recommended purely to improve IVF outcomes — it is reserved for pain, suspicion of malignancy, or access problems at egg collection. Tools such as the Endometriosis Fertility Index help counsel realistically, and fertility preservation (egg freezing) should be discussed early, especially before ovarian surgery or in advanced disease. The recurring principle: the surgery, the IVF and the fertility timeline should be planned together. Read our surgery-or-IVF-first decision framework →

What the guideline does not say

What it means for you

If you have symptoms suggestive of endometriosis, you should not have to wait years or undergo an operation simply to get a name for your pain. You can expect a thorough history, an expert scan, and a frank conversation about medical options — with surgery considered when it is genuinely the right tool, and your fertility and ovarian reserve protected throughout. At Balaji Horizon this is exactly how care is structured: evidence-based, conservative where appropriate, and precise when surgery is truly indicated.

Dr Priyadatt Patel

Endometriosis & Advanced Laparoscopic Surgeon

Dr Patel practises in line with the ESHRE 2022 framework — imaging-led diagnosis, medical therapy first, and ovarian-sparing surgery only when clearly indicated. Because he manages both the surgery and the fertility planning, the trade-offs the guideline describes are owned by one clinician rather than divided across specialties.

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