Endometriosis NICE Diagnosis, management and guidelines Flashcards
What is recommended for organizing care for women with suspected or confirmed endometriosis according to NICE guidelines?
Set up a managed clinical network consisting of community services, gynaecology services, and specialist endometriosis services to provide coordinated care and prompt diagnosis and treatment.
What symptoms should prompt suspicion of endometriosis in women?
Chronic pelvic pain, period-related pain disrupting daily activities, pain during or after sexual intercourse, cyclical gastrointestinal or urinary symptoms, and infertility.
When should women with suspected or confirmed endometriosis be referred according to NICE guidelines?
Refer to gynaecology services for further assessment if symptoms are severe, persistent, or recurrent, and to specialist endometriosis services for deep endometriosis involving bowel, bladder, or ureter.
What are the key diagnostic approaches for endometriosis?
Use transvaginal ultrasound to identify endometriomas and deep endometriosis, consider MRI to assess the extent of deep endometriosis, and use diagnostic laparoscopy as a definitive method if needed.
What are the pharmacological treatments for managing endometriosis-related pain?
Start with a trial of paracetamol or NSAIDs, consider neuromodulators for neuropathic pain, and offer hormonal treatments like oral contraceptives or progestogens.
What surgical options are available for endometriosis management?
Perform laparoscopic surgery for endometriosis, including excision or ablation of lesions and ovarian cystectomy, considering hormonal treatment post-surgery to manage symptoms and prevent recurrence.
What initial signs should lead to a suspicion of endometriosis?
Suspect endometriosis with chronic pelvic pain, period-related pain affecting daily activities, deep pain during or after sexual intercourse, cyclical gastrointestinal or urinary symptoms, and infertility.
What are the initial management steps for suspected endometriosis?
Offer a trial of NSAIDs or hormonal treatment, assess individual support needs, discuss keeping a pain and symptom diary, and conduct an abdominal and pelvic examination. Consider an ultrasound scan.
When should a referral be considered in the management of endometriosis?
Refer to gynaecology or specialist services if initial treatment does not provide adequate pain relief, is not tolerated, or if there are severe, persistent, or recurrent symptoms.
What diagnostic tools should be considered for endometriosis?
Consider transvaginal ultrasound for suspected endometriosis and deep involvement. Do not use pelvic MRI or CA-125 as initial diagnostic tools. Consider laparoscopy if the ultrasound is normal but suspicion remains.
What does surgical management of endometriosis involve?
Discuss surgical options, including laparoscopy, which may include excision or ablation of lesions. Consider systematic inspection and potential biopsy during diagnostic laparoscopy.
How should endometriosis be managed when fertility is a priority?
Avoid hormonal treatment, offer excision or ablation plus adhesiolysis for endometriosis not involving the bowel, bladder, or ureter, and consider the effects on ovarian reserve and future pregnancy chances during surgical planning.
presentation, initial management and referral algorithm
Suspect endometriosis (including in young women aged 17 and under) with 1 or more of:
* chronic 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, blood in the urine or pain passing urine
* infertility in association with 1 or more of the above.
Assess women’s individual information and support needs
Take into account their circumstances, symptoms, priorities, desire for fertility, aspects of daily living,
work and study, cultural background, and their physical, psychosexual and emotional needs.
Also:
* discuss keeping a pain and symptom diary
* offer an abdominal and pelvic examination to identify abdominal masses and pelvic signs
* consider an ultrasound scan (see page 2).
Be aware that endometriosis can be a long-term condition and can
have a significant physical, sexual, psychological and social impact.
Women may have complex needs and may require long-term support.
Offer initial management with:
* a short trial (for example, 3 months) of
paracetamol or a non-steroidal antiinflammatory drug (NSAID) alone or in
combination
* hormonal treatment (combined
contraceptive pill or a progestogen)
* refer to the NICE guideline on neuropathic
pain for treatment with neuromodulators.
If fertility is a priority, the management of
endometriosis-related subfertility should have
multidisciplinary team involvement with input
from a fertility specialist. This should include
recommended diagnostic fertility tests or
preoperative tests and other recommended
fertility treatments such as assisted
reproduction.
Also see Fertility is a priority on page 2.
Consider referral to a gynaecology, paediatric & adolescent gynaecology, or
specialist endometriosis service (endometriosis centre) if:
* a trial of paracetamol or NSAID (alone or in combination) does not provide
adequate pain relief
* initial hormonal treatment for endometriosis is not effective, not tolerated or is
contraindicated.
Consider referral to a
gynaecology service:
* for severe, persistent or
recurrent symptoms of
endometriosis
* for pelvic signs of
endometriosis, or
* if initial management is not
effective, not tolerated or
is contraindicated.
Refer women to a specialist
endometriosis service
(endometriosis centre) if they
have suspected or confirmed
deep endometriosis involving
the bowel, bladder or ureter.
Consider referring young
women (aged 17 and under)
to a paediatric & adolescent
gynaecology service,
gynaecology service or
specialist endometriosis
service (endometriosis
centre), depending on local
service provision.
diagnosis and management algorithm
Do not use pelvic MRI or CA-125 to diagnose endometriosis.
Consider transvaginal ultrasound:
* to investigate suspected endometriosis even if pelvic and/or abdominal examinations are normal
* for endometriomas and deep endometriosis involving the bowel, bladder or ureter.
Consider a transabdominal ultrasound scan of the pelvis if a transvaginal scan is not appropriate.
Do not exclude the possibility of endometriosis if the abdominal and/or pelvic examinations or
ultrasound or MRI are normal.
Consider referral for assessment & investigation if clinical suspicion remains or symptoms persist.
Consider laparoscopy to diagnose endometriosis, even if the ultrasound was normal.
Discuss surgical management options with women with suspected/confirmed endometriosis:
* what laparoscopy involves, and that it may include surgical treatment (with prior patient consent)
* how laparoscopic surgery could affect endometriosis symptoms
* the possible benefits and risks of laparoscopic surgery
* the possible need for further surgery, including the possible need for further planned surgery for
deep endometriosis involving the bowel, bladder or ureter.
During diagnostic laparoscopy, a gynaecologist with training and skills in laparoscopic surgery for
endometriosis should perform a systematic inspection of the pelvis.
If a full systematic laparoscopy is performed and is normal, explain to the woman that she does not
have endometriosis and offer alternative management.
If fertility is a priority If fertility is not currently a priority
Offer excision or ablation plus adhesiolysis to
women with endometriosis not involving
bowel, bladder or ureter.
Offer laparoscopic ovarian cystectomy to
women with endometriomas.
During diagnostic laparoscopy consider
laparoscopic treatment of (if present):
* peritoneal endometriosis not involving the
bowel, bladder or ureter
* uncomplicated ovarian endometriomas.
Consider excision rather than ablation to
Discuss the benefits and risks of laparoscopic treat endometriomas.
surgery for deep endometriosis involving the
bowel, bladder or ureter. This may include:
* effect on the chance of future pregnancy
* the possible impact on ovarian reserve
* the effect of complications on fertility
* alternatives to surgery
* other fertility factors.
Do not offer hormonal treatment to women
with endometriosis who want to conceive.
Consider outpatient follow-up for:
* deep endometriosis involving the bowel,
bladder or ureter, or
* 1 or more endometrioma larger than 3 cm.
For deep endometriosis involving the bowel,
bladder or ureter, consider:
* pelvic MRI before operative laparoscopy
* 3 month course of GnRHa before surgery.
Consider hormonal treatment after
laparoscopic excision or ablation.
If hysterectomy is indicated:
* excise all visible endometriotic lesions at
the time of hysterectomy
* discuss with the woman what a
hysterectomy is, its risks & benefits,
related treatments and likely outcome.
