Guidelines

Investigation and Diagnosis

1st line: TVUS

• Normal findings are common & does NOT exclude endometriosis
• Aim is to screen for other pathologies, identify endometriomas, and deep endometriosis

Definitive test: laparoscopy (direct visualisation of the pelvis) + consider biopsy (to confirm diagnosis – but -ve histology does not exclude endometriosis)

Other tests:

• MRI – consider to diagnose deep or extra-pelvic endometriosis and assess extent (only in secondary care)
• CA125 – do not use to diagnose endometriosis
  • NB: endometriosis can increase CA125 level but has no diagnostic value

Management

Asymptomatic Endometriosis

Expectant management with observation is sufficient for most patients ^[Ref]

Treatment is generally reserved for symptomatic OR complicated asymptomatic cases (e.g., hydronephrosis, large cysts)

Symptomatic Treatment of Endometriosis

Pain Management

1st line: paracetamol and/or NSAID

If the patient is not planning to conceive: offer hormonal treatment (COCP or progestogen)

Surgical Management

1st line: laparoscopic surgery (surgery for endometriosis should be performed laparoscopically, unless contraindicated)

• This can be performed at diagnostic laparoscopy
• Excision / ablation for endometriotic lesions
• Excision is preferred for endometriomas

Last resort but most effective: laparoscopic hysterectomy (+/- oophorectomy) + excision of all endometriotic lesions

Adjuncts

Consider pre-operative GnRH agonist for 3 months in deep endometriosis (i.e., involving the bowel/bladder/ureter)

Consider post-operative hormonal therapy (e.g. COCP or progestogen) to prolong benefits of surgery and manage symptoms.

Preserving / Restoring Fertility

Offer laparoscopic interventions:

• Excision or ablation of endometriosis (not involving the bowel / bladder / ureter)
• Adhesiolysis​​​​​​
• Ovarian cystectomy / laparoscopic drainage and ablation of endometriomas

References

Original Guideline