COMMENTARY

New Guideline: Management of Women With Endometriosis

Peter Kovacs, MD, PhD

Disclosures

March 21, 2014

ESHRE Guideline: Management of Women With Endometriosis

Dunselman GA, Vermeulen N, Becker C, et al
Hum Reprod. 2014;29:400-412

Background

Endometriosis can be diagnosed when endometrial tissue is found in extrauterine locations. It is found in 10%-15% of the general population and in up to one third of the infertile population.[1]There are various theories that attempt to explain its etiology. Some cases can be explained by retrograde menstruation, but metaplasia, hormonal, inflammatory processes, and abnormal cytokine function also seem to play a role.[2]

A wide variety of symptoms may accompany endometriosis. Some women are asymptomatic, whereas others are affected by dysmenorrhea, menorrhagia, dyspareunia, chronic pelvic pain, and urinary and gastrointestinal symptoms. The symptoms typically recur in a cyclic fashion, and an exacerbation can occur around menstruation.

The diagnosis can be suspected on the basis of symptoms but is established when histologic confirmation of endometrial glands and stroma is made from a tissue biopsy sample obtained from an extrauterine location.

Treatment may involve management of the symptoms, medical therapy to suppress endometriosis, and conservative or definitive surgical therapy. The decision is typically made on the basis of the severity of the symptoms, the age of the patient, her wish for future fertility, and potential contraindications to certain therapies.

The Guideline

This guideline is an update of an earlier one aiming to address all important diagnostic and therapeutic issues related to endometriosis.

The authors discuss that various cyclic symptoms and physical findings may raise the possibility of endometriosis, but the gold standard to establish the diagnosis is histologic analysis of tissue samples obtained at the time of surgery. Ultrasonography, MRI, and certain biomarkers may also raise suspicion but should not be used alone to establish diagnosis.

Empirical treatment of pain (without using surgical confirmation) using analgesics or suppressive therapy with oral contraceptive pills (OCPs) may be appropriate for young patients. Hormonal treatment using OCPs, progestins, androgens, and gonadotropin-releasing hormone (GnRH) agonists are all appropriate to manage pain associated with endometriosis. OCPs, especially if use is extended, are appropriate to manage dysmenorrhea and dyspareunia. GnRH agonists with or without hormonal add-back may also be offered to manage painful symptoms.

Surgery and excision or ablation of endometrial implants is also effective to manage endometriosis-associated cyclic symptoms, and providers are encouraged to proceed with removal of endometriosis at the time of diagnosis ("see and treat"). Ovarian endometriomas should be removed by cystectomy, rather than drainage and coagulation, to avoid recurrence. Deep infiltrating endometriosis should be managed by experienced surgeons, because complication rates are high. There is no proven benefit of hormonal treatment as adjuvant therapy to surgery, but nor is there proven harm with this approach. After cystectomy, hormonal therapy may be offered to reduce the risk for recurrence in patients who do not seek immediate conception.

Dietary supplements, transcutaneous nerve stimulation, traditional Chinese medicine, and acupuncture have not shown to be effective for the management of endometriosis.

Medical therapy alone does not improve one’s chance of achieving a pregnancy and should not be offered for this reason. Surgical treatment of early-stage endometriosis improves fertility outcome. Operative laparoscopy can be considered to manage advanced-stage endometriosis (stage III-IV). Before surgical removal of endometriomas, the ovarian reserve should be assessed and the results should be considered. Hormonal treatment after surgical removal of endometriosis has not been shown to improve fertility outcome.

For the infertile patient with early-stage endometriosis (stage I-II), intrauterine insemination can be offered to improve the chance of pregnancy. Success rates of in vitro fertilization seem to be lower among women with endometriosis, but reports are conflicting. GnRH agonist down-regulation for 3-6 months immediately before IVF improves treatment outcome. The removal of larger endometriomas (> 3 cm) has not been shown to improve IVF outcome, although surgery is recommended to those with painful symptoms. After surgical removal of endometriomas and before IVF is started, hormonal therapy may be considered to reduce the risk for recurrence.

Postmenopausal women with a history of endometriosis should be offered combined hormonal treatment instead of estrogen alone if hormone replacement is needed.

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