ACOG Updates Guideline on Diagnosis and Treatment of Endometriosis

Key points

• Endometriosis affects 6 to 10% of women of reproductive age. It is present in approximately 38% of women with infertility and in up to 87% of women with chronic pelvic pain.
• Definitive diagnosis can be made only by histology of surgically removed lesions. Imaging cannot diagnose endometriosis but helps with pelvic or adnexal masses, and transvaginal ultrasonography is the preferred imaging modality.
• Progestins, danazol, extended-cycle combined oral contraceptives, NSAIDs and GnRH agonists can be used for initial pain treatment, but recurrence rates are high after the medication is stopped.
• Laparoscopic surgery gives significant short-term pain improvement, but pain commonly recurs, and endometriomas should be excised rather than simply drained.
• Medical suppressive therapy is ineffective for infertility associated with endometriosis, and after unsuccessful surgery in vitro fertilization is preferred over repeat surgery unless pain persists.

Overview

Endometriosis is a chronic gynecologic disorder that commonly shows up as chronic pain and infertility. This American Family Physician summary reports the American College of Obstetricians and Gynecologists (ACOG) guideline on its diagnosis and treatment, published in Obstetrics & Gynecology in July 2010. Diagnosis needs histology, pain is treated with hormonal drugs or NSAIDs and with surgery, and medical suppression does not help infertility.

Background

The condition is thought to develop when endometrial glands and stroma attach and implant on the peritoneum as a result of retrograde menstruation. Overproduction of prostaglandins and estrogen leads to chronic inflammation in the lesions. How early-stage endometriosis causes infertility is not clear, while ovarian cysts and adhesions in advanced disease can impair tubal function.

Diagnosis

History and examination should rule out other gynecologic causes of pelvic pain, and non-gynecologic causes such as irritable bowel syndrome, interstitial cystitis and urinary tract disorders can be excluded with testing and referral. Imaging cannot be used to diagnose endometriosis. Ovarian endometriomas typically appear on ultrasonography as cysts with low-level homogeneous internal echoes, and imaging alone is highly predictive in distinguishing them from other adnexal masses. Transvaginal ultrasonography is preferred for endometriosis and deeply infiltrating disease of the rectum or rectovaginal septum, and MRI is reserved for equivocal ultrasound results when rectovaginal or bladder endometriosis is suspected.

Treatment of pain

If initial therapy fails, diagnostic laparoscopy can be offered, or empiric treatment with a three-month course of a GnRH agonist if oral contraceptives and NSAIDs have been unsuccessful. A response to empiric therapy does not confirm the diagnosis. For recurrent pain in women who wish to preserve fertility, NSAIDs, combined oral contraceptives and oral or depot medroxyprogesterone acetate are options, followed by progestins, GnRH agonists and androgens. The levonorgestrel-releasing intrauterine system reduces pelvic pain, but irregular bleeding and weight gain are common. When a GnRH agonist works, add-back therapy can reduce or eliminate bone mineral loss without reducing pain relief. Norethindrone 5 mg daily is FDA-approved for this, and calcium 1,000 mg daily is recommended.

Surgery

Laparoscopy with removal of lesions gives significant short-term pain improvement in women who wish to preserve fertility, but pain commonly recurs. Endometriomas should be removed in women with no history of endometriosis, and excision is recommended over simple drainage, which has a high recurrence rate, although removal risks taking normal ovarian tissue and repeat surgery may reduce or abolish ovarian function. Hysterectomy with bilateral salpingo-oophorectomy is generally regarded as definitive therapy for women who do not wish to preserve fertility, and in women with normal ovaries hysterectomy with ovarian conservation and removal of lesions should be considered. Estrogen therapy is not contraindicated afterwards, and endometriosis recurs in up to 15% of women whether or not they receive it.

Infertility

Oral contraceptives and GnRH agonists are ineffective for infertility associated with endometriosis. Surgery improves pregnancy rates, though the size of the improvement is not clear, and excision of deeply infiltrating endometriomas may harm fertility. After an initial unsuccessful operation, in vitro fertilization is preferred over repeat surgery unless pain is still present.

Frequently asked questions

Can imaging diagnose endometriosis?

No. A definitive diagnosis needs histology of surgically removed lesions, although ultrasonography helps to identify ovarian endometriomas and other masses.

Do hormonal treatments help with infertility?

No. Medical suppressive therapy is ineffective for infertility associated with endometriosis. Surgery improves pregnancy rates, and in vitro fertilization is preferred after unsuccessful surgery unless pain persists.

What is add-back therapy?

It is hormone therapy given with a GnRH agonist to reduce or eliminate bone mineral loss without reducing pain relief, for example norethindrone 5 mg daily, with calcium 1,000 mg daily.

Source

Armstrong C. ACOG Updates Guideline on Diagnosis and Treatment of Endometriosis. American Family Physician 2011;83(1):84-85. A summary of the guideline of the American College of Obstetricians and Gynecologists published in Obstetrics & Gynecology, July 2010. This page is a summary prepared by Medpresso from the original publication. It is not a substitute for the full text or for medical advice.