Endometriosis

Overview

These guidelines have been written with the support of Jessica Preshaw (Consultant Gynaecologist, NBT)

Endometriosis is present in approximately 10% of women of reproductive age, many of whom have no symptoms. It can affect women from every social group and ethnicity.

Endometriosis is a hormone mediated chronic inflammatory condition and the precise cause is unclear.

There are three types of endometriosis:

1. Ovarian (causing cysts called endometrioma)
2. Deep (nodules of endometriosis implant ≥5mm below the peritoneum)
3. Superficial peritoneal endometriosis

Types are not mutually exclusive.

Types 1 and 2 can be detected via ultrasound scan and MRI. The gold standard investigation remains laparoscopy.

Endometriosis is treated by medical or surgical methods.

Medical therapies include:

1. Analgesics (paracetamol, NSAIDs or stronger if pain relief not achieved)
2. Hormones such as the oral conceptive pill (combined or progesterone-only), Depo-Provera ™ injection, Nexplanon™ implant and Mirena™ coil or gonadotropin releasing hormone(GnRH) analogues (Zoladex™)

Surgery involves removing the deposits. This is principally completed laparoscopically.

Red Flags

NICE CKS provides information on when to suspect ovarian cancer.

Refer urgently via Gynae 2WW, if examination identifies ascites and/or a pelvic or abdominal mass (not fibroids).

Suspect ovarian cancer and carry out tests:

1. If a woman (especially if 50 years or over) reports any of these symptoms on a persistent or frequent basis (particularly more than 12 times per month):
   • Persistent abdominal distension (bloating)
   • Early satiety and/or loss of appetite
   • Pelvic or abdominal pain
   • Increased urinary urgency and/or frequency

2. If a woman over 50 years experiences symptoms in the last 12 months suggestive of irritable bowel syndrome.
3. If a woman reports unexplained weight loss, fatigue or change in bowel habit.

Before referral

Suspect endometriosis (including in young women aged 17 years and under) with:

• Persistent pelvic pain
• Period-related pain (dysmenorrhoea) affecting daily activities and quality of life
• Deep pain during or after sexual intercourse
• Period-related or cyclical gastrointestinal symptoms, in particular, painful bowel movements
• Period-related or cyclical urinary symptoms, in particular, haematuria or pain passing urine
• Infertility in association with 1 or more of the above.

Offer an abdominal and pelvic examination to identify masses and pelvic signs including reduced organ mobility, tender nodularity in the posterior fornix and endometriotic vaginal nodules.

Organise a pelvic ultrasound (even if the examination is normal). Perform vaginal swabs if indicated. Do not use CA125 to diagnose endometriosis. If coincidentally reported be aware CA125 may be high.

Offer initial management with a trial (e.g. 3 months) of:

• Analgesics (paracetamol or NSAID, alone or in combination)
• Hormonal treatment (combined pill or a progestogen such as the progestogen-only pill, implant (Nexplanon®), injectable (Depot-provera® or Sayana Press®), or levonorgestrel intrauterine system (Mirena®))

Suggest keeping a pain and symptom diary.

Be mindful that endometriosis is a long-term condition and can have a significant physical, sexual, psychological and social impact. Women may have complex needs and require long-term support.

Referral

Consider use of Gynaecology Advice & Guidance service.

Consider referral to secondary care if:

• A trial of paracetamol or NSAID (alone or in combination) does not provide adequate pain relief.
• Initial hormonal treatment is not effective, not tolerated or is contraindicated.

Refer via e-RS to a gynaecology service for severe, persistent or recurrent symptoms of endometriosis, for pelvic signs of endometriosis or if initial management is ineffective, not tolerated or is contraindicated. Choice of providers: Southmead Hospital North Bristol Trust, St Michael's Hospital United Hospitals Bristol and Weston NHS Foundation, Weston General Hospital, Emerson's Green Treatment Centre.

If suspected or confirmed deep endometriosis involving the bowel, bladder or ureter, endometrioma (≥ 3cm) or extra pelvic endometriosis e.g. thoracic endometriosis ensure referral is to an endometriosis centre . Both Southmead Hospital and St Michael’s Hospital are BSGE (British Society of Gynaecological Endoscopy) accredited endometriosis centres providing gynaecologists, specialist nurse, colorectal surgeon, urologist and pain specialist all with expertise in endometriosis.

Refer via eRS to a paediatric and adolescent gynaecology service if aged 17 and under. This is located at St Michael's Hospital.

Refer to fertility (instead or concurrently) if fertility is the main problem and the Fertility Assessment and Treatment Policy criteria are met. Please see Fertility page on Remedy.

resources

Patient support:

Endometriosis UK is a charity that provides free information and support to those with endometriosis. There is a local Bristol support group. (https://www.endometriosis-uk.org)

Pelvic Pain Support Network is an organisation that provides support, information and advocacy for those with pelvic pain, their families and carers. (https://www.pelvicpain.org.uk)

Useful guidelines:

Persistent (Chronic) Pelvic Pain page and Dyspareunia page of Remedy

NICE guideline [NG73] Endometriosis: diagnosis and management September 2017

ESHRE guideline Management of women with endometriosis September 2013

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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