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Endometriosis - Management
Basis for recommendation
Referral if there is a palpable abdominal or pelvic mass
- These recommendations are based on referral guidelines for suspected cancer from the National Institute for Health and Clinical Excellence [NICE, 2005].
Referral for suspected endometriosis
- Referral is recommended because establishing a diagnosis on the basis of symptoms alone is difficult and laparoscopy is the gold standard diagnostic test [RCOG, 2006].
Referral for subfertility
- CKS found no evidence that hormonal treatment improves the chance of pregnancy in women with endometriosis-associated subfertility. Use of the combined oral contraceptive pill, progestogens, androgens, and gonadotrophin-releasing hormone analogues in women with subfertility may cause adverse effects and delay the use of treatment such as surgery, or assisted reproductive techniques.
- Laparoscopic surgery in women with endometriosis-associated subfertility and minimal or mild disease may improve the chance of pregnancy. However, the evidence is conflicting and limited to two small randomized controlled trials.
- Specialized subfertility treatments, such as in vitro fertilization (IVF), may need to be considered in some women. For further information, see the CKS topic on Infertility.
When to consider urgent admission
Seeking advice before prescribing HRT
- There is a lack of evidence about the risks of HRT in perimenopausal women who have endometriosis: HRT may increase the risk of reactivation of the endometriosis, unopposed HRT may increase the risk malignant change in endometriotic deposits, and combined HRT increases the risk of breast cancer. There is also a lack of evidence about the best type of HRT to prescribe (tibolone, continuous-combined HRT, unopposed HRT, or combined HRT). Therefore, CKS recommends seeking specialist advice before initiating HRT. See HRT for more information.
- HRT can also be used as add-back therapy to manage the adverse effects of gonadotrophin-releasing hormone analogues. This is generally prescribed on the advice of a specialist.
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