Without an animal model and a non-invasive diagnosis, the pathophysiology of endometriosis is unclear and information is limited to symptomatic women. Lesions are biochemically variable. Medical therapy cannot be blinded and extensive surgery combines low numbers with variable difficulty and surgical skills. Experience is spread among specialists in imaging, medical therapy, infertility, pain and surgery. Besides the recent changes in interpreting statistical analyses, the limited good-quality evidence increases the importance of clinical experience. Therefore trial design, analysis and judgment of results should be done by experts in the different disciplines of endometriosis, before being translated into guidelines.

This opinion article is endorsed by the World Endometriosis Society (WES) and the International Federation of Fertility Societies (IFFS)The COVID-19 pandemic has led to a dramatic shift in the clinical practice of women’s health and routine care for endometriosis has been severely disrupted. Endometriosis is defined as an inflammatory disease characterised by lesions of endometrial-like tissue outside the uterus that is associated with pelvic pain and/or infertility.1 It affects approximately 10% of reproductive age women worldwide, is diagnosed by surgically visualisation or by radiological imaging, and is treated with hormone treatments or by laparoscopic removal of lesions.2,3Under the guidance of international gynaecological organisations4–6, many centres have temporarily ceased offering outpatient appointments, diagnostic imaging for non-acute pelvic pain, surgery for endometriosis, and fertility treatments. This means that endometriosis sufferers are be feeling particularly vulnerable and that resultant stress and anxiety may contribute to a worsening of symptoms. The pandemic poses several important questions for healthcare providers on how best to deliver care with these restrictions. Herein, we present clinical guidance on the management of endometriosis during the COVID-19 pandemic (Fig. 1).