Endometriosis- NICE +Eshre

Question 1

Symptoms of endometriosis

Answer 1

• Chronic pelvic pain- Dysmenorrhoea, deep dyspareunia
• Cyclical pain
• Dyspareunia
• Cyclical dyschesia
• Cyclical urinary symptoms
• Infertility + one of the above

Question 2

Prevalence

Answer 2

• 2-10% overall
• 50% in infertile women

Question 3

Investigations

Answer 3

• Pain diary
• Abdo pelvic exam- feel for nodules/masses/fixed uterus
• TVUSS - can pick up rectal endo
• MRI- Can be used pre-op if suspicion of severe dis.
• Does not always pick up endo.
• Dx Lap- if no cause found and pain persist

Question 4

Diagnosis

Answer 4

• Do not need to wait for lap
• If clinical suspicion, start treatment

Question 5

Referral to specialist

Answer 5

Local gynae unit-
- Persistent symptoms of endo
- Tried analgesia and hormonal rx w no effect

Specialist endo centre-
- Evidence of endo near bowel/ ureters

Question 6

Dx Lap

Answer 6

• If woman wants a definitive dx, infertility, suspicion of advance disease.
• ALWAYS take biopsies if endo seen- Better for diagnosis
• Done by endo specialist if severe dis.
• If normal- offer alternative mx

Question 7

Mx of endo- medical (can be started by GP)

Answer 7

• Analgesia- NSAIDs, paracetamol, opioids if needed
• Hormonal rx- No negative effect on fertility.
• COCP/POP/ Mirena/GnRH

Question 8

Surgical mx - Lap, minor endo

Answer 8

• Discuss initial dx lap and minor rx.
• Excise not ablate
• Explain risks and benefits- might not find endo

Question 9

Mx of severe endo

Answer 9

• Surgery can improve pain and QoL
• Might need surgery in Endo centre

Question 10

Mx of endometrioma

Answer 10

• Cystectomy better than drainage

Question 11

Adhesion prevention

Answer 11

• Can consider oxidised regenerated cellulose during lap
• Others (tested for pelvic surgery not endo)- hyaluronic acid products

Question 12

GnRH

Answer 12

• Consider for severe endo
• Post op for secondary prevention
• Give w or wo add back therapy

Question 13

Aromatase inhibitors

Answer 13

• Use only if all other options failed
• Use w COCP, POP or GnRH

Question 14

Hysterectomy

Answer 14

• Only if indicated for other reasons or pt fails to respond to all other rx
• Explain might not cure the pain
• Discuss need for HRT if BSO

Question 15

Monitoring if decline surgery

Answer 15

F/u every 3-6 months:
- Deep endo
- 1 or more endometriomas >3cm

Question 16

Other causes if not endo

Answer 16

• IBS
• Chronic PID