A stepped-care approach to symptomatic endometriosis management: a participatory research initiative

Two-thirds of symptomatic patients accepting a stepped-care endometriosis management were satisfied with oral contraceptives and a low-cost progestin, and few had to step up to a high-cost progestin or surgery.

Volume 109, Issue 6, Pages 1086–1096


Paolo Vercellini, M.D., Agnese Donati, M.D., Federica Ottolini, M.D., Annalisa Frassineti, Jessica Fiorini, Vanessa Nebuloni, Maria Pina Frattaruolo, M.D., Anna Roberto, Biol.Sci.D., Paola Mosconi, Biol.Sci.D., Edgardo Somigliana, M.D.



To assess the proportion of patients with symptomatic endometriosis satisfied with their medical treatment 12 months after enrollment in a stepped-care management protocol.


Prospective, single-arm, self-controlled study.


Academic department.


A cohort of 157 consecutive patients referred or self-referred to our center for symptomatic endometriosis.


Systematic detailed information process on medical and surgical treatment followed by a shared decision to start a stepped-care protocol including three subsequent medical therapy steps (oral contraception [OC]; 2.5 mg/d norethindrone acetate [NETA]; 2 mg/d dienogest [DNG]) and a fourth surgical step. Stepping up was triggered by drug inefficacy/intolerance.

Main Outcome Measure(s)

Satisfaction with treatment was assessed according to a five-category scale (very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, very dissatisfied). Variations were measured in pain symptoms with the use of a 0–10-point numeric rating scale (NRS), in quality of life with the use of the Short Form 12 questionnaire (SF-12), and in sexual functioning with the use of the Female Sexual Function Index (FSFI).


At the end of the 12-month study period, 106 women were still using OC, 23 were using NETA, three were using DNG, and four had undergone surgery. Twenty-one participants (13%) dropped out from the study. In intention-to-treat analysis, excluding five drop-outs for pregnancy desire, the overall satisfaction rate with the stepped-care protocol was 62% (95/152; 95% CI 55%–70%). By 12-month follow-up, significant improvements were observed in all pain symptom scores and in SF-12 physical and mental component summary scores, whereas FSFI scores did not vary substantially.


Most women with endometriosis-associated pelvic pain who chose a stepped-care approach were satisfied with OC and a low-cost progestin for the treatment of their symptoms. The need to step up to an expensive progestin or surgery was marginal.

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