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Endometriosis - Management
How should I manage a woman with suspected endometriosis?

  • Consider referring all women with suspected endometriosis to a gynaecologist (especially women with severe symptoms or subfertility) to confirm the diagnosis by laparoscopy, and for medical or surgical management.
  • The choice regarding referral and treatment depends on:
    • The wishes of the woman.
    • The severity and duration of symptoms.
    • Requirements for fertility.
    • Previous treatment.
    • Abnormalities identified on pelvic ultrasound or clinical examination.
  • Prescribe analgesia for women who are awaiting referral or who do not wish to be referred, if symptoms are troublesome and the women does not require contraception or does not wish to take hormonal treatment.
    • A nonsteroidal anti-inflammatory drug (NSAID, such as ibuprofen, naproxen, mefenamic acid, or diclofenac) is recommended first-line. Ibuprofen may be preferred because of its more favourable risk–benefit ratio.
    • Offer paracetamol if an NSAID is poorly tolerated or contraindicated, or in addition to an NSAID if the response is insufficient. Regular use may be more effective than as-required use.
    • Codeine (15 mg or 30 mg) may be added to paracetamol and/or an NSAID if the response is insufficient.
  • If symptoms are troublesome and are not sufficiently controlled with analgesics or contraception is required, consider prescribing hormonal treatment.
    • Consider an ultrasound scan to rule out a pelvic mass (such as an endometrioma) before prescribing hormonal treatment.
    • Consider the combined oral contraceptive (COC) pill, first-line.
      • Monophasic COCs containing 30–35 micrograms of ethinylestradiol, and either norethisterone or levonorgestrel, are usually the first choice.
      • It is not known whether the COC should be taken conventionally, continuously without a break, or in a tricycling regimen to control endometriosis.
      • CKS suggests a three month trial of conventional treatment, then switching to tricycling after three months if necessary. Some women may find continuous use helpful.
    • Consider a progestogen if the COC is contraindicated:
      • A 3-month course of medroxyprogesterone (not contraceptive).
      • A 4–6-month course of norethisterone (not contraceptive).
    • A progestogen-only contraceptive is a further alternative.
      • Not all women will achieve amenorrhoea with this method.
      • If symptom relief is not obtained after a 3–6 month trial, consider switching to an alternative hormonal method or refer.
    • Suitable progestogen-only contraceptives include the levonorgestrel-releasing intra-uterine system (Mirena®), Cerazette® (a progestogen-only pill), depot medroxyprogesterone acetate (Depo-Provera®), or the etonogestrel subdermal contraceptive implant (Nexplanon® [formely Implanon®]).
    • See the CKS topic on Contraception for detailed information on prescribing hormonal contraceptives. Whilst licensed for contraceptive use, the COC, Cerazette®, Depo-Provera®, Mirena®, and Implanon® are not specifically licensed for the treatment of endometriosis.
  • Review after 10–12 weeks (earlier if symptoms are troublesome). Refer if there is no improvement.

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