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Endometriosis

Key sources
The following summarized guidelines for the evaluation and management of endometriosis are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2023; 2010), the European Society of Human Reproduction and Embryology (ESHRE 2022), and the American College of Obstetricians and Gynecologists (ACOG 2018; 2016; 2010).
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Guidelines

1.Screening and diagnosis

Clinical presentation: recognize that:
symptoms of endometriosis may vary, but certain hallmark symptoms may be more likely to suggest endometriosis; recognize the atypical presentations
A
endometriosis can be a chronic, relapsing disorder, which may necessitate a long-term follow-up
A
adolescent patients with endometriosis are more likely than adult patients to present with acyclic pain
B
physical examination of adolescent patients with endometriosis will rarely reveal abnormalities, as most will have early-stage disease
B
endometriosis in adolescent patients is often early-stage and atypical.
B
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  • Diagnosis

2.Diagnostic investigations

History and physical examination: as per ESHRE 2022 guidelines, consider performing a clinical examination, including vaginal examination where appropriate, to identify deep nodules or endometriomas in patients with suspected endometriosis, although the diagnostic accuracy is low.
B

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  • Diagnostic imaging

  • Laboratory studies

3.Diagnostic procedures

Diagnostic laparoscopy: consider performing laparoscopy for the diagnosis and treatment of suspected endometriosis in patients with negative imaging results or if empirical treatment was unsuccessful or inappropriate.
C

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  • Biopsy

4.Medical management

Hormone therapy: as per ESHRE 2022 guidelines, offer hormone treatment (combined hormonal contraceptives, progestogens, gonadotropin releasing hormone agonists or gonadotropin releasing hormone antagonists) as an option to reduce endometriosis-associated pain.
A
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  • GnRH agonists/antagonists

  • Aromatase inhibitors

  • Analgesics

5.Nonpharmacologic interventions

Alternative and complementary therapies
Discuss non-medical strategies to address QoL and psychological well-being in patients managing symptoms of endometriosis.
B
Insufficient evidence to recommend any specific non-medical intervention (Chinese medicine, nutrition, electrotherapy, acupuncture, physiotherapy, exercise, and psychological interventions) to reduce pain or improve QoL measures in patients with endometriosis.
I

6.Therapeutic procedures

Hormone-releasing intrauterine device: offer a levonorgestrel-releasing intrauterine system or an etonogestrel-releasing subdermal implant to reduce endometriosis-associated pain in patients with endometriosis.
A

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  • Fertility preservation

7.Perioperative care

Preoperative hormone therapy: do not offer preoperative hormone therapy to improve the immediate outcome of surgery for pain in patients with endometriosis.
D
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8.Surgical interventions

Indications for surgery: as per ESHRE 2022 guidelines, offer surgery as one of the options to reduce endometriosis-associated pain.
A
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  • Excision of endometrioma

  • Hysterectomy

  • Presacral neurectomy

9.Specific circumstances

Asymptomatic patients: as per ESHRE 2022 guidelines, inform and counsel patients about any incidental finding of endometriosis.
B
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  • Adolescent patients (diagnosis)

  • Adolescent patients (management)

  • Adolescent patients (fertility preservation)

  • Pregnant patients

  • Postmenopausal patients

  • Patients with infertility (medical management)

  • Patients with infertility (operative laparoscopy)

  • Patients with infertility (ART)

  • Patients with extrapelvic endometriosis

10.Patient education

General counseling: inform patients with endometriosis requesting information on their risk of developing cancer that endometriosis is not associated with a significantly higher risk of cancer overall. Inform that although endometriosis is associated with a higher risk of ovarian, breast, and thyroid cancers in particular, the increase in absolute risk compared with women in the general population is low.
A
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11.Preventative measures

Primary prevention
Consider advising females to follow a healthy lifestyle and diet, with reduced alcohol intake and regular physical activity.
C
Insufficient evidence to support the usefulness of hormonal contraceptives for the primary prevention of endometriosis.
I

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  • Prevention of recurrence

12.Follow-up and surveillance

Indications for referral: refer patients with deep endometriosis to a center of expertise.
B

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  • Follow-up

  • Management of recurrence

13.Quality improvement

Management outcomes: as per SOGC 2010 guidelines, recognize that:
treatment of endometriosis by excision or ablation reduces pain
A
excision rather than drainage or fulguration provides better pain relief, a reduced recurrence rate, and a histopathological diagnosis in patients with endometriomas
A
laparoscopic uterine nerve ablation alone does not offer significant relief of endometriosis-related pain
A
laparoscopic treatment of minimal or mild endometriosis improves pregnancy rates regardless of the treatment modality
A
the effect on fertility of surgical treatment of deeply infiltrating endometriosis is controversial
B
laparoscopic excision of ovarian endometriomas > 3 cm in diameter may improve fertility
B
if a patient with known endometriosis is to undergo IVF, GnRH agonist suppression with add-back hormone therapy for 3 to 6 months before IVF is associated with an improved pregnancy rate.
A