New clinical guidelines about endometriosis by the nation\u2019s 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.\u00a0<\/p>\n\n\n\n
In March 2026, the American College of Obstetricians and Gynecologists (ACOG)<\/a> released a Clinical Practice Guideline <\/a>on endometriosis, replacing a 2010 practice bulletin and 2018 committee opinion. The release<\/a> of the document is timely given the relatively high prevalence of endometriosis in the population at large, especially in women with unexplained infertility <\/a>and\/or chronic pelvic pain [1].\u00a0<\/p>\n\n\n\n The guidelines contains a series of recommendations<\/em>, based on a review of available research, plus good practice points<\/em>, which reflect areas where \u201cclinical 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.\u201d\u00a0<\/p>\n\n\n\n A \u2018strong recommendation\u2019 means \u201cbenefits clearly outweigh the harms. Most patients should receive the intervention.\u201d \u201cACOG recommends against\u201d means \u201cHarms and burdens clearly outweigh the benefits. Most patients should not receive the intervention.\u201d <\/p>\n\n\n\n ACOG made three strong recommendations. <\/p>\n\n\n\n The first was that a clinical diagnosis of endometriosis, which could be made through \u201ca symptom-based assessment, physical examination, or both\u201d should be considered \u201csufficient to initiate empiric medical treatment.\u201d This recommendation was based on low-quality evidence, meaning \u201crandomized controlled trials with serious flaws. Some evidence from observational studies.\u201d <\/p>\n\n\n\n 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 \u201crandomized controlled trials with some limitations. Strong evidence from observational studies without serious methodologic flaws or limitations.\u201d <\/p>\n\n\n\n The third recommended against<\/em> 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<\/a>, in an Instagram post dated January 29, 2025.)<\/p>\n\n\n\n The guidelines \u2018conditionally recommended,\u2019 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).\u00a0<\/p>\n\n\n\n Perhaps most tellingly, the majority of ACOG\u2019s guidance came in the form of \u201cgood practice points\u201d rather than from high-quality evidence. <\/p>\n\n\n\n Importantly, clinicians trained in family medicine, internal medicine, and pediatrics, not just OB\/GYN practitioners, \u201cshould 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.\u201d<\/p>\n\n\n\n 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. <\/p>\n\n\n\n The guidelines suggested that in patients suspected to have endo, deciding between diagnostic laparoscopic surgery and \u201cempiric medical treatment\u201d (read: hormonal suppression through hormonal birth control<\/a> or through medications like Orilissa<\/a> that put the body into a menopause-like state<\/a>) should be \u201cindividualized based on a shared decision-making discussion of the benefits and risks of each approach.\u201d\u00a0<\/p>\n\n\n\n ACOG notes that a laparoscopy \u201ccan 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.\u201d Additionally, during a diagnostic laparoscopy, a biopsy \u201cshould be considered,\u201d though a negative result \u201cdoes not exclude the possibility of endometriosis.\u201d Finally, \u201cSuspected endometriosis lesions should be treated at the time of initial laparoscopy, when possible, to help avoid the need for additional surgery.\u201d <\/p>\n\n\n\n Advocacy for earlier diagnosis plus increased suspicion for endometriosis in women and girls who present with certain symptoms represent the guidelines\u2019 strongest points. On average, 7 to 10 years<\/a> elapse from symptom onset to endometriosis diagnosis. ACOG\u2019s new guidance represents a step towards decreasing that unacceptable timeframe [2].\u00a0<\/p>\n\n\n\n The document repeatedly mentions endometriosis symptoms in teenage <\/em>girls, acknowledging that this disease can occur much earlier<\/a> 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).\u00a0<\/p>\n\n\n\n The document repeatedly mentions endometriosis symptoms in teenage <\/em>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). <\/p><\/blockquote><\/figure>\n\n\n\n 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\u2014and deserve. <\/p>\n\n\n\n The most glaring issue with ACOG\u2019s new guidelines is its failure to tap into the goldmine of endo knowledge and experience that NaProTECHNOLOGY-trained clinicians<\/a>, restorative reproductive medicine (RRM) practitioners<\/a>, and endometriosis experts are utilizing in clinical practice every day.\u00a0<\/p>\n\n\n\n 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<\/a> have spent decades honing endometriosis assessment and root-cause treatment.\u00a0<\/p>\n\n\n\n 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<\/a> have spent decades honing endometriosis assessment and root-cause treatment.\u00a0<\/p><\/blockquote><\/figure>\n\n\n\n What\u2019s more, as Utah-based endometriosis expert Dr. Jeff Arrington observed<\/a>, in some ways the ACOG guidelines represents a new name for status quo medical practice.\u00a0<\/p>\n\n\n\n While ACOG urges practitioners to consider endometriosis when a patient has certain signs and symptoms, the \u201cempiric medical treatment\u201d (read: hormonal suppression) routinely prescribed to \u201ctreat\u201d 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.\u00a0<\/p>\n\n\n\n In fact, these new guidelines beg the question: What\u2019s the point of working up endometriosis specifically if the same Band-Aid treatment would be applied for nonspecific period pain?\u00a0<\/p>\n\n\n\n As one example, while the ACOG document recommends imaging<\/em> to diagnose endometriosis, Dr. Naomi Whittaker explained here<\/a> that imaging doesn\u2019t allow proper assessment of the extent, depth, or location of endometriosis lesions. <\/p>\n\n\n\n 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<\/a>. (Dr. Whittaker has developed a free, three-tiered self screening tool<\/a> to help women know when they should reach out to a medical practitioner for an endometriosis workup.)<\/p>\n\n\n\n Finally, the ACOG document focuses heavily on diagnosis, with little mention made of treatments, let alone distinguishing evidence-based (hint: excision surgery<\/a> by a surgeon who does many, many such procedures) from ineffective surgeries (looking at you, ablation or cauterization of superficial endometriosis lesions<\/a>). <\/p>\n\n\n\n In reality, experts like St. Louis-based Dr. Patrick Yeung are pursuing \u201cone-and-done\u201d<\/a> surgery with extremely low<\/a> rates of recurrence (endometriosis lesions growing back<\/a>) [3]. These surgeries typically involve \u201cnear-contact\u201d<\/a> techniques as invented by Dr. David Redwine<\/a>, as well as Systematic Mapping of the Abdomen and Pelvic (S-MAP) as developed by NaPro pioneer Dr. Thomas Hilgers [4].\u00a0<\/p>\n\n\n\n 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<\/a> often offer a wider array of tools, including supplementation with N-acetylcysteine <\/a>on its own or in combination with other antioxidants<\/a>, and\/or Low-dose Naltrexone<\/a>, as well as bioidentical progesterone supplementation targeted to the woman\u2019s luteal phase [5].\u00a0<\/p>\n\n\n\n We celebrate ACOG\u2019s 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.\u00a0<\/p>\n\n\n\n References<\/p>\n\n\n\n [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.<\/p>\n\n\n\n [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.<\/p>\n\n\n\nWhat the new ACOG endometriosis guidelines say<\/span><\/h2>\n\n\n\n
Strong recommendations<\/span><\/h3>\n\n\n\n
Conditional recommendation<\/span><\/h3>\n\n\n\n
Good Practice Points<\/span><\/h3>\n\n\n\n
Laparoscopy<\/span><\/h3>\n\n\n\n
Wins: What ACOG’s new endometriosis guidelines get right<\/span><\/h2>\n\n\n\n
Missed opportunities: Where ACOG’s new endometriosis guidelines fall short<\/span><\/h2>\n\n\n\n
Failure to utilize decades of experience and knowledge from NaPro and RRM practitioners<\/span><\/h3>\n\n\n\n
Band-Aid relief, no matter what the underlying cause<\/span><\/h3>\n\n\n\n
Endo diagnosis requires laparoscopic surgery<\/span><\/h3>\n\n\n\n
Little mention of treatment options<\/span><\/h3>\n\n\n\n
The bottom line<\/span><\/h2>\n\n\n\n