HNY Policy and Pathway Repository - York

• Presence of endometrial-like tissue outside the uterus, which induces a chronic, inflammatory reaction. Some women experience painful symptoms and/or infertility, others have no symptoms. Prevalence 2-10% of reproductive age women or up to 50% of infertile women.
• Consider the diagnosis when patient has following symptoms:
  • Dysmenorrhoea, non-cyclical pelvic pain, deep dyspareunia, infertility, difficulties with defaecation, rectal bleeding,dysuria, haematuria.

• Laparoscopy and biopsy are considered “gold standard” for diagnosis of endometriosis and to exclude malignancy.

• Ultrasound is recommended (usually abdominal and transvaginal) to diagnose and to detect endometrioma/mass in pelvis or ovaries that may need further investigation.
• Empirical treatment with adequate analgesia, combined hormone contraceptives or progestogens for at least 6 months before considering further investigation.
  • If symptoms controlled, no need for further referral.

Treatment Options:

Combined hormone contraceptives:

• Can be given continuously to reduce dyspareunia, dysmenorrhoea, and non-menstrual pain.
• Break through bleeding may occur after a few months but can be controlled by having a break of 5 days and then starting CHC again.
• Vaginal contractive ring and transdermal patch reduces chronic pelvic pain as well as symptoms above.
• Progestogens- oral or depot or IUS-– can reduce pain and control bleeding.
• GnRH agonists- (Zoladex, prostap)- usually initiated in secondary care- can be used to reduce pain and control bleeding. May need add-back HRT to help with symptoms.
• NSAIDs- should be considered to reduce pain; but used in caution if a patient is trying to conceive as associated with a higher miscarriage rate.
• If patient stops treatment above because wanting to become pregnant, follow RSS Guidelines on Subfertility.

Information to include in referral letter

• Symptoms that could be caused by endometriosis
• Treatment tried to date and results
• Relevant past medical/surgical history
• Current regular medication including any hormonal contraception
• BMI/Smoking status
• Smear Status
• Contraceptive history
• Vaginal examination
   

Investigations prior to referral

• Ultrasound of pelvis

Patient information leaflets/ PDAs

• RCOG Patient guide to endometriosis
   

References

• ESHRE European Society of Human Reproduction and Embryology –Management of women with endometriosis.