Endometriosis

Recognition

• About 10 percent of reproductive-age women; the average delay to diagnosis is years, mostly because cyclical pain is normalised.
• Symptoms: dysmenorrhoea that worsens over time, deep dyspareunia, dyschezia, dysuria, chronic pelvic pain, subfertility, fatigue.
• Examination: tenderness or nodularity of the uterosacral ligaments, a fixed retroverted uterus, an adnexal mass; often normal.
• Imaging: transvaginal ultrasound for endometrioma and deep disease in expert hands; MRI for deep infiltrating disease. A normal scan does not exclude superficial peritoneal disease.
• The SOGC guideline supports a clinical diagnosis and empirical treatment without laparoscopy; surgery is for diagnosis where it will change management, for endometriomas, for deep disease, and for fertility in selected cases.

Treatment

1. 1

   First line

   NSAIDs and hormonal suppression: combined hormonal contraception (continuous), or a progestin (dienogest, norethindrone, the levonorgestrel IUD, the implant, depot medroxyprogesterone).

2. 2

   Second line

   GnRH antagonists (elagolix) or agonists with add-back therapy; aromatase inhibitors in selected cases.

3. 3

   Surgery

   Laparoscopic excision or ablation of lesions, cystectomy for endometriomas (with the cost of ovarian reserve), excision of deep nodules in specialist centres; hysterectomy with or without oophorectomy for those who have completed their family.

4. 4

   Fertility

   Assisted reproduction is often more effective than surgery for endometriosis-associated infertility; surgery may help in selected minimal to moderate disease.

5. 5

   The whole person

   Pelvic physiotherapy, pain science education, psychological support, and treating the bowel and bladder components.