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## Complete Summary

#### GUIDELINE TITLE

The investigation and management of endometriosis.

#### BIBLIOGRAPHIC SOURCE(S)

Royal College of Obstetricians and Gynaecologists (RCOG). The
investigation and management of endometriosis. London (UK): Royal
College of Obstetricians and Gynaecologists (RCOG); 2006 Oct. 14
p. (Green-top guideline; no. 24). \[69 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Endometriosis

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Obstetrics and Gynecology\
Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To provide clinicians with up-to-date information about the diagnosis
and treatment of endometriosis, based upon the best available evidence

#### TARGET POPULATION

Women with endometriosis

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis**

1.  Assessment of symptoms

2.  Timing of clinical examination (during menstruation)

3.  Laparoscopic visual inspection of the pelvis

4.  Transvaginal ultrasound

**Management/Treatment**

1.  Medical treatment of endometriosis-associated pain

    -   Hormonal drugs for suppression of ovarian function

    -   Levonorgestrel intrauterine system

2.  \"Add-back (estrogen and progestogen) therapy for prevention of bone
    mineral density loss while taking a gonadotrophin-releasing hormone
    (GnRH) agonist

3.  Surgical treatment of endometriosis-associated pain: ablation of
    endometriotic lesions

4.  Treatment of endometriosis associated infertility

    -   Surgical treatment: ablation of endometriotic lesions plus
        adhesiolysis

    -   Laparoscopic cystectomy for ovarian endometriomas

    -   Flushing the fallopian tubes

5.  Assisted reproduction in endometriosis

    -   Intrauterine insemination (IUI)

    -   In vitro fertilisation (IVF)

    -   Treatment with a GnRH agonist (prior to IVF)

#### MAJOR OUTCOMES CONSIDERED

-   Sensitivity and specificity of diagnostic tests

-   Symptom relief

-   Surgical complication rates

-   Pregnancy rate

-   Adverse effects of drug therapy

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The Cochrane Library (including the Cochrane Database of Systematic
Reviews, DARE, and EMBASE), TRIP, Medline, and PubMed (electronic
databases) were searched for relevant randomised controlled trials,
systematic reviews, and meta-analyses. The search was restricted to
articles published in English between January 2000 and April 2006.
Recent consensus documents were also studied. The databases were
searched using the relevant Medical Subject Heading (MeSH) terms
including all sub-headings and this was combined with a keyword search.
Main keywords included \"endometriosis,\" \"endometriosis, diagnosis,\"
\"endometriosis, drug therapy,\" \"endometriosis, complications,\"
\"endometriomas,\" \"endometriosis, surgery.\"

A guideline, *The Diagnosis and Treatment of Endometriosis*, produced by
the European Society for Human Reproduction and Embryology (ESHRE)
Special Interest Group for Endometriosis and the Endometrium Guideline
Development Group, published in 2005, was consulted in producing this
guideline. The ESHRE guideline is updated regularly and made available
at
[www.endometriosis.org/guidelines.html](http://www.endometriosis.org/guidelines.html)
with hyperlinks to the supporting evidence and the relevant references
and abstracts. The ESHRE guideline was developed without a systematic
search of the published literature; it relied instead on existing review
journals, such as *Clinical Evidence*.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**Ia**: Evidence obtained from meta-analyses of randomised controlled
trials

**Ib**: Evidence obtained from at least one randomised controlled trial

**IIa**: Evidence obtained from at least one well-designed controlled
study without randomisation

**IIb**: Evidence obtained from at least one other type of well-designed
quasi-experimental study

**III**: Evidence obtained from well-designed non-experimental
descriptive studies, such as comparative studies, correlation studies,
and case studies

**IV**: Evidence obtained from expert committee reports or opinions
and/or clinical experience of respected authorities

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

The recommendations were graded according to the level of evidence upon
which they were based. The grading scheme used was based on a scheme
formulated by the Clinical Outcomes Group of the National Health Service
Executive.

**Grade A** - Requires at least one randomised controlled trial as part
of a body of literature of overall good quality and consistency
addressing the specific recommendation. (Evidence levels Ia, Ib)

**Grade B** - Requires the availability of well controlled clinical
studies but no randomised clinical trials on the topic of
recommendations. (Evidence levels IIa, IIb, III)

**Grade C** - Requires evidence obtained from expert committee reports
or opinions and/or clinical experiences of respected authorities.
Indicates an absence of directly applicable clinical studies of good
quality. (Evidence level IV)

#### COST ANALYSIS

Published cost analyses were reviewed that compared the cost profiles of
combined oral contraceptives, danazol, gestrinone, medroxyprogesterone
acetate, and gonadotrophin-releasing hormone (GnRH) agonists.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Following discussion in the Guidelines and Audit Committee, each
green-top guideline is formally peer reviewed. At the same time the
draft guideline is published on the Royal College of Obstetricians and
Gynaecologists Web site for further peer review discussion before final
publication.

The names of author(s) and nominated peer reviewers are included in the
original guideline document.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

*In addition to these evidence-based recommendations, the guideline
development group also identifies points of best clinical practice in
the original guideline document*.

Levels of evidence (**Ia-IV**) and grading of recommendations (**A-C**)
are defined at the end of the \"Major Recommendations\" field.

**Diagnosis**

**Which Symptoms are Typically Associated with Endometriosis?**

**C** - Based on clinical and patient experience, endometriosis can
cause the following symptoms:

-   Severe dysmenorrhoea

-   Deep dyspareunia

-   Chronic pelvic pain

-   Ovulation pain

-   Cyclical or perimenstrual symptoms, such as bowel or bladder, with
    or without abnormal bleeding or pain

-   Infertility

-   Chronic fatigue

-   Syschezia (pain on defaecation).

**When in the Menstrual Cycle is Clinical Examination Most Reliable for
Diagnostic Purposes?**

**B** - Deeply infiltrating nodules are most reliably detected when
clinical examination is performed during menstruation.

Finding pelvic tenderness, a fixed, retroverted uterus, tender
uterosacral ligaments, or enlarged ovaries on examination is suggestive
of endometriosis. The findings may, however, be normal. The diagnosis is
more certain if deeply infiltrating nodules are palpated on the
uterosacral ligaments or in the pouch of Douglas and/or visible lesions
are seen in the vagina or on the cervix. The detection of nodules is
improved by performing the clinical examination during menstruation
although patient acceptance may be an issue. (Evidence level III)

**What is the \"Gold Standard\" Diagnostic Test?**

**B** - For a definitive diagnosis of endometriosis, visual inspection
of the pelvis at laparoscopy is the gold standard investigation, unless
disease is visible in the posterior vaginal fornix or elsewhere.

**How Reliable is Imaging for Diagnostic Purposes?**

**A** - Compared with laparoscopy, transvaginal ultrasound (TVS) has
limited value in diagnosing peritoneal endometriosis but it is a useful
tool both to make and to exclude the diagnosis of an ovarian
endometrioma.

**How Reliable is Serum CA125 Measurement for Diagnostic Purposes?**

**A** - Serum CA125 levels may be elevated in endometriosis. However,
compared with laparoscopy, measuring serum CA125 levels has no value as
a diagnostic tool.

**Medical Treatment of Endometriosis-Associated Pain**

**How Effectively Do Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Treat
Endometriosis-Associated Pain?**

**A** - There is inconclusive evidence to show whether NSAIDs
(specifically naproxen) are effective in managing pain caused by
endometriosis.

**How Effectively Do Hormonal Drugs Treat Endometriosis-Associated
Pain?**

**A** - Suppression of ovarian function for 6 months reduces
endometriosis-associated pain.

**B** - Symptom recurrence is common following medical treatment of
endometriosis.

**Is There a Role For the Levonorgestrel Intrauterine System
(LNG-IUS)?**

**A** - The LNG-IUS appears to reduce endometriosis-associated pain.

**Can Bone Mineral Density Loss While Taking a Gonadotrophin-Releasing
Hormone (GnRH) Agonist be Prevented Using \"Add-Back\" Therapy?**

**A** - The use of a GnRH agonist with \"add-back\" (oestrogen and
progestogen) therapy protects against bone mineral density loss at the
lumbar spine during treatment and for up to 6 months after treatment.

**Surgical Treatment of Endometriosis-Associated Pain**

**When Should Surgical Treatment Be Considered?**

Depending upon the severity of disease found, ideal practice is to
diagnose and remove endometriosis surgically, provided that adequate
preoperative consent has been obtained.

**Does Surgical Treatment Relieve Pain?**

**A** - Ablation of endometriotic lesions reduces
endometriosis-associated pain compared with diagnostic laparoscopy.

**Does Nerve Ablation Provide Pain Relief?**

**A** - Laparoscopic uterine nerve ablation by itself does not reduce
endometriosis-associated pain.

**Is There a Role For Hormonal Treatment Before or After Surgery?**

**A** - There is insufficient evidence of benefit to justify the use of
preoperative or postoperative hormonal treatment.

**Treatment of Endometriosis-Associated Infertility**

**Is There a Role For Hormonal Treatment in Endometriosis-Associated
Infertility?**

**A** - Suppression of ovarian function to improve fertility in
minimal--mild endometriosis is not effective and should not be offered
for this indication alone. There is no evidence of its effectiveness in
more severe disease.

**Does Surgery for Minimal--Mild Disease Improve Pregnancy Rates?**

**A** - Ablation of endometriotic lesions plus adhesiolysis to improve
fertility in minimal--mild endometriosis is effective compared with
diagnostic laparoscopy alone.

**Does Surgery for Moderate--Severe Disease Improve Pregnancy Rates?**

**B** - The role of surgery in improving pregnancy rates for
moderate-severe disease is uncertain.

**How Should Ovarian Endometriomas be Managed?**

**A** - Laparoscopic cystectomy for ovarian endometriomas is better than
drainage and coagulation.

**Is There a Role for Hormonal Treatment After Surgery?**

**A** - Postoperative hormonal treatment has no beneficial effect on
pregnancy rates after surgery.

**Is There a Role for Flushing the Fallopian Tubes?**

**A** - Tubal flushing appears to improve pregnancy rates in women with
endometriosis-associated infertility.

**Assisted Reproduction in Endometriosis**

**Does Intrauterine Insemination (IUI) Improve Pregnancy Rates?**

**A** - Treatment with IUI improves fertility in minimal to mild
endometriosis.

**Is In Vitro Fertilisation (IVF) Indicated?**

**B** - IVF is appropriate treatment, especially if tubal function is
compromised, if there is also male factor infertility, and/or other
treatments have failed.

**Is There a Role for Hormonal Treatment Before IVF?**

**A** - Treatment with a GnRH agonist for 3 to 6 months before IVF in
women with endometriosis increases the rate of clinical pregnancy.

**Coping with Disease**

**What is the role for complementary therapies?**

**C** - The role of complementary therapies in relieving
endometriosis-associated pain is unclear.

**Definitions**:

**Grading of Recommendations**

**Grade A** - Requires at least one randomised controlled trial as part
of a body of literature of overall good quality and consistency
addressing the specific recommendation. (Evidence levels Ia, Ib)

**Grade B** - Requires the availability of well controlled clinical
studies but no randomised clinical trials on the topic of
recommendations. (Evidence levels IIa, IIb, III)

**Grade C** - Requires evidence obtained from expert committee reports
or opinions and/or clinical experiences of respected authorities.
Indicates an absence of directly applicable clinical studies of good
quality. (Evidence level IV)

**Levels of Evidence**

**Ia**: Evidence obtained from meta-analyses of randomised controlled
trials

**Ib**: Evidence obtained from at least one randomised controlled trial

**IIa**: Evidence obtained from at least one well-designed controlled
study without randomisation

**IIb**: Evidence obtained from at least one other type of well-designed
quasi-experimental study

**III**: Evidence obtained from well-designed non-experimental
descriptive studies, such as comparative studies, correlation studies,
and case studies

**IV**: Evidence obtained from expert committee reports or opinions
and/or clinical experience of respected authorities

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate management of endometriosis to control pain, increase
pregnancy rate, and protect against bone mineral density loss

#### POTENTIAL HARMS

-   Adverse effects of drug therapy

-   Diagnostic laparoscopy is associated with an approximately 3% risk
    of minor complications, such as nausea or shoulder tip pain, and a
    risk of major complications, such as bowel perforation, vascular
    damage, of between 0.6/1000 and 1.8/1000.

-   Complications of surgery

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   These guidelines are \"systematically developed statements which
    assist clinicians and patients in making decisions about appropriate
    treatment for specific conditions.\" Each guideline is
    systematically developed using a standardised methodology. Exact
    details of this process can be found in Clinical Governance Advice
    No. 1: Guidance for the Development of RCOG Green-top Guidelines
    (See the \"Availability of Companion Documents\" field in this
    summary.)

-   These recommendations are not intended to dictate an exclusive
    course of management or treatment. They must be evaluated with
    reference to individual patient needs, resources and limitations
    unique to the institution and variations in local populations. It is
    hoped that this process of local ownership will help to incorporate
    these guidelines into routine practice. Attention is drawn to areas
    of clinical uncertainty where further research may be indicated.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Audit Criteria/Indicators

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Royal College of Obstetricians and Gynaecologists (RCOG). The
investigation and management of endometriosis. London (UK): Royal
College of Obstetricians and Gynaecologists (RCOG); 2006 Oct. 14
p. (Green-top guideline; no. 24). \[69 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006 Oct

#### GUIDELINE DEVELOPER(S)

Royal College of Obstetricians and Gynaecologists - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

Royal College of Obstetricians and Gynaecologists

#### GUIDELINE COMMITTEE

Guidelines and Audit Committee of the Royal College of Obstetricians and
Gynaecologists

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Mr SH Kennedy, MRCOG, Oxford and Miss SJ Moore, MRCOG, Oxford

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Guideline authors are required to complete a \"declaration of
interests\" form.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Royal College of Obstetricians and Gynaecologists (RCOG) Web
site](http://www.rcog.org.uk/resources/public/pdf/endometriosis_gt_24_2006.pdf).

Print copies: Available from the Royal College of Obstetricians and
Gynaecologists (RCOG) Bookshop, 27 Sussex Place, Regent\'s Park, London
NW1 4RG; Telephone: +44 020 7772 6276; Fax, +44 020 7772 5991; e-mail:
<bookshop@rcog.org.uk>. A listing and order form are available from the
[RCOG Web site](http://www.rcogbookshop.com/).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Development of RCOG green-top guidelines: policies and processes.
    Clinical Governance Advice No 1a. 2006 Nov. Available from the
    [Royal College of Obstetricians and Gynaecologists (RCOG) Web
    site](http://www.rcog.org.uk/index.asp?PageID=1776).

-   Development of RCOG green-top guidelines: producing a scope.
    Clinical Governance Advice No 1b. 2006 Nov. Available from the
    [Royal College of Obstetricians and Gynaecologists (RCOG) Web
    site](http://www.rcog.org.uk/index.asp?PageID=1777).

-   Development of RCOG green-top guidelines: producing a clinical
    practice guideline. Clinical Governance Advice No 1c. 2006 Nov.
    Available from the [Royal College of Obstetricians and
    Gynaecologists (RCOG) Web
    site](http://www.rcog.org.uk/index.asp?PageID=1778).

-   Searching for evidence. Clinical Governance Advice No 3. 2001 Oct.
    Available from the [Royal College of Obstetricians and
    Gynaecologists (RCOG) Web
    site](http://www.rcog.org.uk/index.asp?PageID=481).

Additionally, auditable standards can be found in section 13 of the
[original guideline
document](http://www.rcog.org.uk/resources/public/pdf/endometriosis_gt_24_2006.pdf).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on November 29, 2007.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008