In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
Levels of evidence (Ia-IV) and grading of recommendations (A-C) are defined at the end of the "Major Recommendations" field.
Diagnosis
Which Symptoms are Typically Associated with Endometriosis?
C - Based on clinical and patient experience, endometriosis can cause the following symptoms:
- Severe dysmenorrhoea
- Deep dyspareunia
- Chronic pelvic pain
- Ovulation pain
- Cyclical or perimenstrual symptoms, such as bowel or bladder, with or without abnormal bleeding or pain
- Infertility
- Chronic fatigue
- Syschezia (pain on defaecation).
When in the Menstrual Cycle is Clinical Examination Most Reliable for Diagnostic Purposes?
B - Deeply infiltrating nodules are most reliably detected when clinical examination is performed during menstruation.
Finding pelvic tenderness, a fixed, retroverted uterus, tender uterosacral ligaments, or enlarged ovaries on examination is suggestive of endometriosis. The findings may, however, be normal. The diagnosis is more certain if deeply infiltrating nodules are palpated on the uterosacral ligaments or in the pouch of Douglas and/or visible lesions are seen in the vagina or on the cervix. The detection of nodules is improved by performing the clinical examination during menstruation although patient acceptance may be an issue. (Evidence level III)
What is the "Gold Standard" Diagnostic Test?
B - For a definitive diagnosis of endometriosis, visual inspection of the pelvis at laparoscopy is the gold standard investigation, unless disease is visible in the posterior vaginal fornix or elsewhere.
How Reliable is Imaging for Diagnostic Purposes?
A - Compared with laparoscopy, transvaginal ultrasound (TVS) has limited value in diagnosing peritoneal endometriosis but it is a useful tool both to make and to exclude the diagnosis of an ovarian endometrioma.
How Reliable is Serum CA125 Measurement for Diagnostic Purposes?
A - Serum CA125 levels may be elevated in endometriosis. However, compared with laparoscopy, measuring serum CA125 levels has no value as a diagnostic tool.
Medical Treatment of Endometriosis-Associated Pain
How Effectively Do Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Treat Endometriosis-Associated Pain?
A - There is inconclusive evidence to show whether NSAIDs (specifically naproxen) are effective in managing pain caused by endometriosis.
How Effectively Do Hormonal Drugs Treat Endometriosis-Associated Pain?
A - Suppression of ovarian function for 6 months reduces endometriosis-associated pain.
B - Symptom recurrence is common following medical treatment of endometriosis.
Is There a Role For the Levonorgestrel Intrauterine System (LNG-IUS)?
A - The LNG-IUS appears to reduce endometriosis-associated pain.
Can Bone Mineral Density Loss While Taking a Gonadotrophin-Releasing Hormone (GnRH) Agonist be Prevented Using "Add-Back" Therapy?
A - The use of a GnRH agonist with "add-back" (oestrogen and progestogen) therapy protects against bone mineral density loss at the lumbar spine during treatment and for up to 6 months after treatment.
Surgical Treatment of Endometriosis-Associated Pain
When Should Surgical Treatment Be Considered?
Depending upon the severity of disease found, ideal practice is to diagnose and remove endometriosis surgically, provided that adequate preoperative consent has been obtained.
Does Surgical Treatment Relieve Pain?
A - Ablation of endometriotic lesions reduces endometriosis-associated pain compared with diagnostic laparoscopy.
Does Nerve Ablation Provide Pain Relief?
A - Laparoscopic uterine nerve ablation by itself does not reduce endometriosis-associated pain.
Is There a Role For Hormonal Treatment Before or After Surgery?
A - There is insufficient evidence of benefit to justify the use of preoperative or postoperative hormonal treatment.
Treatment of Endometriosis-Associated Infertility
Is There a Role For Hormonal Treatment in Endometriosis-Associated Infertility?
A - Suppression of ovarian function to improve fertility in minimal–mild endometriosis is not effective and should not be offered for this indication alone. There is no evidence of its effectiveness in more severe disease.
Does Surgery for Minimal–Mild Disease Improve Pregnancy Rates?
A - Ablation of endometriotic lesions plus adhesiolysis to improve fertility in minimal–mild endometriosis is effective compared with diagnostic laparoscopy alone.
Does Surgery for Moderate–Severe Disease Improve Pregnancy Rates?
B - The role of surgery in improving pregnancy rates for moderate-severe disease is uncertain.
How Should Ovarian Endometriomas be Managed?
A - Laparoscopic cystectomy for ovarian endometriomas is better than drainage and coagulation.
Is There a Role for Hormonal Treatment After Surgery?
A - Postoperative hormonal treatment has no beneficial effect on pregnancy rates after surgery.
Is There a Role for Flushing the Fallopian Tubes?
A - Tubal flushing appears to improve pregnancy rates in women with endometriosis-associated infertility.
Assisted Reproduction in Endometriosis
Does Intrauterine Insemination (IUI) Improve Pregnancy Rates?
A - Treatment with IUI improves fertility in minimal to mild endometriosis.
Is In Vitro Fertilisation (IVF) Indicated?
B - IVF is appropriate treatment, especially if tubal function is compromised, if there is also male factor infertility, and/or other treatments have failed.
Is There a Role for Hormonal Treatment Before IVF?
A - Treatment with a GnRH agonist for 3 to 6 months before IVF in women with endometriosis increases the rate of clinical pregnancy.
Coping with Disease
What is the role for complementary therapies?
C - The role of complementary therapies in relieving endometriosis-associated pain is unclear.
Definitions:
Grading of Recommendations
Grade A - Requires at least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation. (Evidence levels Ia, Ib)
Grade B - Requires the availability of well controlled clinical studies but no randomised clinical trials on the topic of recommendations. (Evidence levels IIa, IIb, III)
Grade C - Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality. (Evidence level IV)
Levels of Evidence
Ia: Evidence obtained from meta-analyses of randomised controlled trials
Ib: Evidence obtained from at least one randomised controlled trial
IIa: Evidence obtained from at least one well-designed controlled study without randomisation
IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study
III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies
IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities
