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Endometriosis – Information for GPs

Definition

Presence of endometrial-like tissue outside the uterus, which induces a chronic, inflammatory reaction. Some women experience painful symptoms and/or infertility, others have no symptoms. Prevalence 2-10% of reproductive age women or up to 50% of infertile women.

Consider the diagnosis when patient has following symptoms:

  • Dysmenorrhoea, non-cyclical pelvic pain, deep dyspareunia, infertility, difficulties with defaecation, rectal bleeding, dysuria, haematuria

Red flag symptoms

Laparoscopy and biopsy are considered ‘gold standard’ for diagnosis of endometriosis and to exclude malignancy.

Management

  • Ultrasound is recommended (usually abdominal and transvaginal) to diagnose and detect endometrioma/mass in pelvis or ovaries that may need further investigation
  • Empirical treatment with adequate analgesia, combined hormone contraceptives or progestogens for at least 6 months before considering further investigation
  • If symptoms controlled, no need for further referral

Treatment options

Combined hormone contraceptives (CHC) – see joint formulary

  • Can be given continuously to reduce dyspareunia, dysmenorrhoea and non-menstrual pain
  • Break through bleeding may occur after a few months but can be controlled by having a break of 5 days and then starting CHC again

Progestogens – oral or depot or IUS – can reduce pain and control bleeding

GnRH agonists – (Zoladex, prostap) – usually initiated in secondary care under shared care guidelines. Can be used to reduce pain and control bleeding. May need add-back HRT to help with symptoms

NSAIDs – should be considered to reduce pain; but used in caution if a patient is trying to conceive as associated with a higher miscarriage rate

If patient stops treatment above because wanting to become pregnant, follow RSS guidelines on Subfertility.

Investigations prior to referral

Ultrasound of pelvis

Information to include in referral letter

  • Symptoms that could be caused by endometriosis
  • Treatment tried to date and results
  • Relevant past medical / surgical history
  • Current regular medication including any hormonal contraception
  • BMI
  • Smoking status
  • Smear status
  • Contraceptive history
  • Vaginal examination

Patient information

  1. RCOG Patient Guide to Endometriosis
  2. Audio version of the leaflet – click here
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