Endometriosis – Treatment
Obstetrics and Gynecology
Context
- See the Endometriosis Diagnosis Clinical Summary for details on the patient population. This treatment review focuses on females presenting with pelvic pain for which other critical diagnoses have been excluded, and a presumptive endometriosis diagnosis has been made.
- Endometriosis is common and often a chronic relapsing disorder that necessitates long term follow up. Suspecting the diagnosis early, starting appropriate treatment, and organizing follow up are key for long term management.
- Factors that cause endometriosis to progress, regress, or remain stable are not yet known.
Context
Medical Management (1st line):
Mild – Moderate Symptoms (not causing regular school/work absence):
- NSAIDs: Short courses of NSAIDs, ideally 1-2 days prior to onset of menses (ensuring no NSAID contraindications are present).
- No particular NSAID has been shown to be superior for endometriosis treatment.
AND/OR
- Continuous Hormonal Contraceptive:
- Estrogen-progestin combined contraceptives preferred if no estrogen contraindications.
- In women with contraindications consider progestin-only contraceptive including an IUD (through clinic or gyne).
Severe Symptoms (disabling, regularly causing school/work absence):
- Discuss management with OBGYN team who may consider.
- Diagnostic laparoscopy.
- GnRH agonist with add-back hormonal therapy.
- While awaiting resolution of symptoms from the directed medical or surgical treatments for severe endometriosis, clinical judgement should be used in prescribing appropriate analgesics ranging from NSAIDs to opioids.
Complimentary Treatment:
- Pelvic floor physiotherapy.
- Mindfulness/CBT.
- Regular exercise, adequate sleep and a healthy diet.
Criteria For Hospital Admission
- Severe pain requiring regular opioids for adequate analgesia.
- Women with symptomatic or expanding endometriomas where a laparoscopic procedure may need to be performed to prevent rupture or ovarian torsion.
Criteria For Close Observation And/or Consult
OBGYN consult is likely indicated if:
- Symptoms are severe or persistent.
- Symptoms refractory to NSAIDs and continuous hormonal contraceptives.
- Symptoms that suggest invasion of deep structures (dyschezia, dyspareunia, dysuria).
Criteria For Safe Discharge Home
- Critical pelvic pain diagnoses have been excluded.
- Pain is reasonably controlled, and the patient has a plan for ongoing analgesia options.
- Follow up has been arranged with primary care or OBGYN.
Quality Of Evidence?
High
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
Moderate
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
Low
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Justification
Treatments based on systematic reviews and recommendations from the society of obstetricians and gynecologists of Canada.
Related Information
Reference List
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SOGC Endometriosis Working Group. Management of Symptoms Associated with Suspected or Confirmed Endometriosis. April 2020.
Giudice LC. Clinical practice. Endometriosis. N Engl J Med 2010; 362:2389-98
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Relevant Resources
RESOURCE AUTHOR(S)
DISCLAIMER
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Dec 05, 2020
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