• European researchers have created new guidelines for the diagnosis and treatment of endometriosis.
• They provided important updates to five key areas of disease management, including diagnosis, treatment and recurrence.
• The new guidelines could help patients and clinicians better understand and manage the disease.

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

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

• painful cramps, 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
• tired
• pain during intercourse
• spotting or bleeding between periods
• infertility

Although it is a common condition, people are often only diagnosed with it 8-12 years old after the onset of symptoms. More specific guidelines could improve the diagnosis and treatment of people with the disease.

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

“These guidelines offer better ways to manage and treat endometriosis for doctors and hope and comfort for millions of women who have felt frustrated and hopeless with this debilitating disease,” Dr Sherry RossOB/GYN and women’s health expert at Providence Saint John’s Health Center in Santa Monica, Calif., said Medical News Today.

Diagnostic

In the previous 2014 Guidelineslaparoscopy – a surgical procedure involving small inclusions in the abdomen to insert a camera – was considered the gold standard diagnostic tool.

Due to recent advances in imaging modalities, operative risk, limited access to highly skilled surgeons, and cost implications, ESHRE now only recommends laparoscopy if imaging results are negative and unsuccessful or inappropriate treatments.

Pain treatment

These 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 can ease postoperative pain, the guidelines note that it may affect conception if taken continuously.

Infertility treatment

Prolonged use of GnRH agonists before assisted reproductive technologies (ART) – including in vitro fertilization – is no longer recommended to increase fertility due to uncertain benefits.

Meanwhile, the Endometriosis Fertility Index (EFI) has been added as a treatment step to help patients decide how to achieve pregnancy after surgery.

Recurrence

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

They add that ART does not increase recidivism in women deep endometriosis — a single nodule more than 1 centimeter (cm) in diameter outside the uterus or near the lower 20 cm of the intestine.

In conversation with DTM, Dr. Yen Hope TranOB/GYN at MemorialCare Orange Coast Medical Center in Fountain Valley, Calif., noted that the guidelines also recommend that surgeons “perform cystectomy instead of drainage and coagulation because cystectomy reduces the recurrence of ‘endometrioma and pain associated with endometriosis’.

Adolescence

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

“Teenagers and their doctors often don’t discuss endometriosis — or endo symptoms — in the few meetings they’re likely to have. I find it helpful to ask them if they should miss classes or skip the school because of their symptoms,” she added.

When diagnosing and treating adolescent girls, guidelines recommend that clinicians carefully investigate possible risk factors for endometriosis, including positive family history, obstructive genital malformations, early first menstrual period, and short menstrual cycle.

To treat endometriosis in teenage girls, 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 in adolescents with endometriosis.

the World Health Organization (WHO) also recommends that if GnRH agonists are being considered for adolescent girls and young women, 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. Teenage girls with endometriosis need to be educated about the risk of becoming infertile so they can make a more informed decision about early surgery, egg preservation and other steps if they ever wish to have children,” said Dr Tran.

ESHRE hopes the new guidelines will help both patients and healthcare professionals better understand and treat endometriosis.

When asked what the main points for patients and clinicians to consider in these guidelines are, Dr. Tran replied:

“Endometriosis is a serious disease. It may cause up to 50% of all cases of infertility [and] each case is different. Any correlation between getting pregnant and experiencing relief from symptoms of endometriosis is considered rare and amounts 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 needed. You are never out of trouble with endometriosis. caused by endo continue to cause problems for women even after menopause,” she explained.

“Talk to your doctor, don’t delay treatment. Symptom relief is possible. Fertility preservation must begin immediately; endometriosis is serious and should be taken seriously,” she concluded.