New guidelines may improve diagnosis, treatment

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Endometriosis is a common gynecological condition that affects thousands of girls and women. Catherine McQueen/Getty Images
  • Researchers in Europe have created new guidelines for diagnosing and treating endometriosis.
  • They have made significant updates to five key areas in managing the condition, including diagnosis, treatment, and recurrence.
  • The new guidelines could help patients and clinicians better understand and manage the condition.

Endometriosis is a condition in which tissue similar to the lining inside the uterus grows outside the uterus. It affects around 190 million — or 10% — of women and girls of reproductive age worldwide.

Although some people with endometriosis are asymptomatic, common symptoms include:

  • painful cramping, similar to menstrual cramps
  • long-term lower back and pelvic pain
  • abnormal periods
  • bowel and urinary problems, including pain, diarrhea, constipation, and bloating
  • blood in the stool or urine
  • nausea and vomiting
  • fatigue
  • pain during intercourse
  • spotting or bleeding between periods
  • infertility

While this is a common condition, people often only receive a diagnosis for it 8-12 years after symptom onset. More specific guidelines could improve diagnosis and treatment for people with the condition.

In a recent report, the European Society of Human Reproduction and Embryology (ESHRE) developed new clinical practice guidelines for diagnosing and treating endometriosis.

“These guidelines offer better ways to manage and treat endometriosis for physicians and hope and comfort for millions of women who have felt frustrated and desperate by this debilitating disease,” Dr. Sherry Ross, OB/GYN and Women’s Health Expert at Providence Saint John’s Health Center in Santa Monica, CA, told Medical News Today.

Diagnosis

In the previous 2014 guidelines, laparoscopy — a surgical procedure involving small inclusions in the abdomen to insert a camera — was considered the gold standard diagnostic tool.

Due to recent advancements in imaging modalities, operative risk, limited access to highly-qualified surgeons, and financial implications, the ESHRE now only recommends laparoscopy if imaging results are negative and unsuccessful or inappropriate treatments.

Pain treatment

The present guidelines now recommend GnRH agonist or GnRH antagonist treatments — which prevent the ovaries from making sex hormones by desensitizing the pituitary gland — as a second-line treatment option.

They also say that NSAIDs may aid postoperative pain, the guidelines note that this may affect conception if taken continually.

Infertility treatment

Extended use of GnRH agonists before assisted reproduction techniques (ARTs) — including in vitro fertilization — is no longer recommended to increase fertility due to unclear benefits.

Meanwhile, the Endometriosis Fertility Index (EFI) was added as a treatment step to help patients decide how to achieve pregnancy postsurgery.

Recurrence

The current guidelines recommend hormone treatments, including combined hormonal contraceptives for at least 18-24 months after surgery to prevent a recurrence.

They add that ART does not increase recurrence in women with deep endometriosis — a single nodule larger than 1 centimeter (cm) in diameter outside the uterus or close to the lower 20 cm of the bowel.

In conversation with MNT, Dr. Yen Hope Tran, OB/GYN at MemorialCare Orange Coast Medical Center in Fountain Valley, CA, noted that the guidelines also recommend surgeons “perform cystectomy instead of drainage and coagulation, as cystectomy reduces recurrence of endometrioma and endometriosis-associated pain.”

Adolescence

“Often, endometriosis manifests in adolescence, even early adolescence, but teens are unlikely to know that their pain and other symptoms are not the norm,” said Dr. Tran. “Period pain during this time is not normal.”

“Teens and their physicians often don’t address endometriosis — or endo symptoms — in the few meetings they are likely to have. I find it useful to ask about them having to miss classes/skip school because of their symptoms,” she added.

When diagnosing and treating adolescents, the guidelines recommend clinicians carefully investigate possible risk factors for endometriosis, including positive family history, obstructive genital malformations, early first menstruation, and a short menstrual cycle.

To treat endometriosis in adolescents, they recommend hormonal contraceptives or progesterone as first-line hormone therapy.

The American College of Obstetricians and Gynecologists recommends NSAIDs as the mainstay of pain relief for adolescents with endometriosis.

The World Health Organization (WHO) Also recommends that if GnRH agonists are considered for adolescents and young women, the potential side effects and long-term health risks should first be discussed with a clinician in a secondary or tertiary setting.

“[The guidelines emphasize] preservation of fertility. Adolescents with endometriosis should be informed of the risk of becoming infertile so that they can make a more informed decision about early surgical intervention, preservation of oocytes, and other steps should they ever want to have children,” said Dr. Tran.

The ESHRE hopes that the new guidelines will assist both patients and healthcare professionals in better understanding and dealing with endometriosis.

When asked what the main points are for patients and clinicians to be aware of from these guidelines, Dr. Tran said:

“Endometriosis is a serious disease. It causes perhaps as much as 50% of all cases of infertility [and] Each case is different. Any correlation between getting pregnant and experiencing relief of endometriosis symptoms are regarded as rare, and amount to wishful thinking.”

“Endometriosis recurs quite frequently, and no one treatment is appropriate for every patient or every case. Later in life, different treatments may be called for. You’re never out of the woods with endometriosis. Damage from endo continues to cause problems for women even after menopause,” she explained.

“Talk to your doctor, don’t put off treatment. Relief from symptoms is possible. Preservation of fertility needs to start immediately; endometriosis is serious and should be taken seriously,” she concluded.

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