New clinical guidelines about endometriosis by the nation’s leading professional organization for OB/GYNs highlights the need for clinicians in other medical specialties (internal medicine, family practice, and pediatrics) to suspect endometriosis when a patient presents with certain signs and symptoms, and to refer to specialists accordingly.
In March 2026, the American College of Obstetricians and Gynecologists (ACOG) released a Clinical Practice Guideline on endometriosis, replacing a 2010 practice bulletin and 2018 committee opinion. The release of the document is timely given the relatively high prevalence of endometriosis in the population at large, especially in women with unexplained infertility and/or chronic pelvic pain [1].
What the new ACOG endometriosis guidelines say
The guidelines contains a series of recomendaciones, based on a review of available research, plus good practice points, which reflect areas where “clinical guidance is deemed necessary in the case of extremely limited or nonexistent evidence. [Good practice points] are based on expert opinion as well as review of the available evidence.”
A ‘strong recommendation’ means “benefits clearly outweigh the harms. Most patients should receive the intervention.” “ACOG recommends against” means “Harms and burdens clearly outweigh the benefits. Most patients should not receive the intervention.”
Strong recommendations
ACOG made three strong recommendations.
The first was that a clinical diagnosis of endometriosis, which could be made through “a symptom-based assessment, physical examination, or both” should be considered “sufficient to initiate empiric medical treatment.” This recommendation was based on low-quality evidence, meaning “randomized controlled trials with serious flaws. Some evidence from observational studies.”
The second encouraged transvaginal ultrasounds as the first-line type of imaging to look for suspected endometriosis. This recommendation was based on moderate-quality evidence, meaning “randomized controlled trials with some limitations. Strong evidence from observational studies without serious methodologic flaws or limitations.”
The third recommended contra using any type of blood or urine test or other biomarker to diagnose endometriosis, and this was also based on low-quality evidence. (NaPro-trained endometriosis surgeon Dr. Naomi Whittaker similarly pointed this out, in an Instagram post dated January 29, 2025.)
Conditional recommendation
The guidelines ‘conditionally recommended,’ meaning that risks and benefits will vary based on the patient, pelvic MRI to guide treatment planning in patients who appeared to have deep endometriosis (presumably based on results of other imaging, such as an ultrasound).
Good Practice Points
Perhaps most tellingly, the majority of ACOG’s guidance came in the form of “good practice points” rather than from high-quality evidence.
Importantly, clinicians trained in family medicine, internal medicine, and pediatrics, not just OB/GYN practitioners, “should suspect a diagnosis of endometriosis in [patients] who present with one or more of the following cyclic or noncyclic signs and symptoms: chronic pelvic pain, dysmenorrhea, dyspareunia, dyschezia, or infertility associated with one or more of these symptoms.”
Furthermore, over-the-belly ultrasound is suggested for girls and women who cannot tolerate transvaginal ultrasound, such as those who have never had sex or who have suffered sexual trauma.
Laparoscopia
The guidelines suggested that in patients suspected to have endo, deciding between diagnostic laparoscopic surgery and “empiric medical treatment” (read: hormonal suppression through anticonceptivos hormonales or through medications like Orilissa that put the body into a menopause-like state) should be “individualized based on a shared decision-making discussion of the benefits and risks of each approach.”
ACOG notes that a laparoscopy “can be considered in patients with suspected endometriosis to confirm the diagnosis even if the results of a physical exam or imaging are negative. However, diagnostic lap is not required to initiate empiric medical treatment.” Additionally, during a diagnostic laparoscopy, a biopsy “should be considered,” though a negative result “does not exclude the possibility of endometriosis.” Finally, “Suspected endometriosis lesions should be treated at the time of initial laparoscopy, when possible, to help avoid the need for additional surgery.”
Wins: What ACOG’s new endometriosis guidelines get right
Advocacy for earlier diagnosis plus increased suspicion for endometriosis in women and girls who present with certain symptoms represent the guidelines’ strongest points. On average, 7 to 10 years elapse from symptom onset to endometriosis diagnosis. ACOG’s new guidance represents a step towards decreasing that unacceptable timeframe [2].
The document repeatedly mentions endometriosis symptoms in adolescente girls, acknowledging that this disease can occur much earlier than previously assumed. Hopefully, catching endometriosis much sooner can prevent infertility caused by decades of worsening, untreated scarring and adhesions (where endometriosis tissue sticks together, causing further pain, bleeding with periods, and additional scarring).
The document repeatedly mentions endometriosis symptoms in adolescente girls, acknowledging that this disease can occur much earlier than previously assumed. Hopefully, catching endometriosis much sooner can prevent infertility caused by decades of worsening untreated scarring and adhesions (where endometriosis tissue sticks together, causing further pain, bleeding with periods, and additional scarring).
Missed opportunities: Where ACOG’s new endometriosis guidelines fall short
While it’s encouraging that ACOG is finally revisiting its practice guidelines for endometriosis, the updates are unfortunately full of missed opportunities to encourage OB/GYNs to offer the kind of care that girls and women suffering from endometriosis truly need—and deserve.
Failure to utilize decades of experience and knowledge from NaPro and RRM practitioners
The most glaring issue with ACOG’s new guidelines is its failure to tap into the goldmine of endo knowledge and experience that NaProTECHNOLOGY-trained clinicians, restorative reproductive medicine (RRM) practitioners, and endometriosis experts are utilizing in clinical practice every day.
While mainstream medicine has for decades prescribed hormonal birth control (and, more recently, medications that put the body into a menopause-like hormonal state) to mask endometriosis symptoms or reduce pain that continues after endo surgery, NaPro practitioners, clinicians trained in RRM, and endometriosis experts have spent decades honing endometriosis assessment and root-cause treatment.
While mainstream medicine has for decades prescribed hormonal birth control (and, more recently, medications that put the body into a menopause-like hormonal state) to mask endometriosis symptoms or reduce pain that continues after endo surgery, NaPro practitioners, clinicians trained in RRM, and endometriosis experts have spent decades honing endometriosis assessment and root-cause treatment.
Band-Aid relief, no matter what the underlying cause
What’s more, as Utah-based endometriosis expert Dr. Jeff Arrington observado, in some ways the ACOG guidelines represents a new name for status quo medical practice.
While ACOG urges practitioners to consider endometriosis when a patient has certain signs and symptoms, the “empiric medical treatment” (read: hormonal suppression) routinely prescribed to “treat” it is no different than the hormonal birth control that has been recommended for decades when women present with heavy periods, irregular cycles, and more.
In fact, these new guidelines beg the question: What’s the point of working up endometriosis specifically if the same Band-Aid treatment would be applied for nonspecific period pain?
Endo diagnosis requires laparoscopic surgery
As one example, while the ACOG document recommends imágenes to diagnose endometriosis, Dr. Naomi Whittaker explained aquí that imaging doesn’t allow proper assessment of the extent, depth, or location of endometriosis lesions.
Definitive diagnosis, Dr. Whittaker and other RRM-trained physicians insist, can only come through a diagnostic laparoscopy, specifically performed by a physician who regularly performs endometriosis surgery and is familiar with all its varying appearances and potential locations. (Dr. Whittaker has developed a free, three-tiered self screening tool to help women know when they should reach out to a medical practitioner for an endometriosis workup.)
Little mention of treatment options
Finally, the ACOG document focuses heavily on diagnosis, with little mention made of treatments, let alone distinguishing evidence-based (hint: cirugía de escisión by a surgeon who does many, many such procedures) from ineffective surgeries (looking at you, ablation or cauterization of superficial endometriosis lesions).
In reality, experts like St. Louis-based Dr. Patrick Yeung are pursuing "de una vez" surgery with extremadamente bajo rates of recurrence (endometriosis lesions growing back) [3]. These surgeries typically involve “near-contact” techniques as invented by Dr. David Redwine, as well as Systematic Mapping of the Abdomen and Pelvic (S-MAP) as developed by NaPro pioneer Dr. Thomas Hilgers [4].
When it comes to endometriosis symptom relief, conventional medical doctors may encourage exercise, self-care, counseling, nutrition coaching, and other practices as part of an effective treatment plan. In addition to endometriosis excision surgery, RRM-trained doctors and NaPro practitioners often offer a wider array of tools, including supplementation with N-acetilcisteína on its own or in combination with other antioxidantsy/o Low-dose Naltrexone, as well as bioidentical progesterone supplementation targeted to the woman’s luteal phase [5].
Lo esencial
We celebrate ACOG’s efforts to increase awareness and early diagnosis of endometriosis, especially in young women. Unfortunately, their new guidelines failed to capitalize on the clinical expertise of NaPro- and RRM-trained clinicians and endometriosis experts, which represents a major missed opportunity in improving endometriosis care for more women in the United States.
Referencias
[1] Nezhat C, Khoyloo F, Tsuei A, Armani E, Page B, Rduch T, Nezhat C. The Prevalence of Endometriosis in Patients with Unexplained Infertility. J Clin Med. 2024 Jan 13;13(2):444. doi: 10.3390/jcm13020444. PMID: 38256580; PMCID: PMC11326441. [2] De Corte P, Klinghardt M, von Stockum S, Heinemann K. Time to Diagnose Endometriosis: Current Status, Challenges and Regional Characteristics-A Systematic Literature Review. BJOG. 2025 Jan;132(2):118-130. doi: 10.1111/1471-0528.17973. Epub 2024 Oct 7. Erratum in: BJOG. 2025 Jun;132(7):1018. doi: 10.1111/1471-0528.18149. PMID: 39373298; PMCID: PMC11625652. [3] Yeung, P.; Mohan, A.; Gavard, J. The Long-term Rate of Repeat Surgery After Optimal Excision Surgery of Endometriosis at a Single Tertiary Referral Center. Preprints 2024, 2024091485. https://doi.org/10.20944/preprints202409.1485.v1 [4] Petersen NF, Rhoe J. Endometriosis. Obtaining relief via ‘near-contact’ laparoscopy. AORN J. 1988 Oct;48(4):700-7, 710-2. doi: 10.1016/s0001-2092(07)69125-x. PMID: 3190209. [5] Lete I, Mendoza N, de la Viuda E, Carmona F. Effectiveness of an antioxidant preparation with N-acetyl cysteine, alpha lipoic acid and bromelain in the treatment of endometriosis-associated pelvic pain: LEAP study. Eur J Obstet Gynecol Reprod Biol. 2018 Sep;228:221-224. doi: 10.1016/j.ejogrb.2018.07.002. Epub 2018 Jul 6. PMID: 30007250.