INDEX

    Endometriosis – Treatment

    Obstetrics and Gynecology

    Last Updated Dec 05, 2020
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    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?

    Justification

    Treatments based on systematic reviews and recommendations from the society of obstetricians and gynecologists of Canada.

    Moderate

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