TAUFIK RECOMENDATIONS 3

 ENDOMETRIOSIS: DIAGNOSIS AND MANAGEMENT

JOGC, Volume 32, Number 7, July  2010. Supplement 2

Chapter 1: Introduction

Summary Statements

1. Endometriosis is common, affecting 5% to 10% of the female population, and the significance of the disease depends on the clinical presentation. (II-3)

2. The cellular and molecular etiologic theories of endometriosis as an inflammatory and estrogen-dependent disorder have improved our understanding. (III)

Chapter 2: Pain Management

Summary Statements

1. Symptoms may vary; however, certain hallmark symptoms may be more likely to sug gest endometriosis. The clinician should be aware of atypical presentations.(I)

2. Endometriosis can be a chronic, relapsing disorder, which may necessitate a long-term follow-up.(I)

3. When deeply infiltrating endometriosis is suspected, a pelvic examination, including rectovaginal examination, is essential.(III)

Recommendations

1. Investigation of suspected endometriosis should include history, physical, and imaging assessments.(III-A)

2. Routine CA-125 testing as part of the diagnostic investigation of endometriosis should not be performed (II-2D)

Chapter 3: Medical Management of Pain Associated With Endometriosis

Recommendations

1. Combined hormonal contraceptives, ideally administered continuously, should be considered as first-line agents. (I-A)

2. Administration of progestin alone orally, intramuscularly, or subcutaneously—may also be considered as first-line therapy. (I-A)

3. A GnRH agonist with HT addback, or the LNG-IUS, should be considered a second-line therapeutic option. (I-A)

4. A GnRH agonist should be combined with HT addback therapy from commencement of therapy and may be considered for longer-term use (> 6 months). (I-A)

5. While awaiting resolution of symptoms from the directed medical or surgical treatments for endometriosis, practitioners should use clinical judgement in prescribing analgesics ranging from NSAIDs to opioids. (III-A)

Chapter 4: Surgical Management of Endometriosis

Summary Statements

1. Treatment of endometriosis by excision or ablation reduces pain. (I)

2. For women with endometriomas, excision rather than drainage or fulguration provides better pain relief, a reduced recurrence rate, and a histopathological diagnosis. (I)

3. Laparoscopic uterine nerve ablation alone does not offer significant relief of endometriosis-related pain(I)

Recommendations

1. An asymptomatic patient with an incidental finding of endometriosis at the time of surgery does not require any medical or surgical intervention. (III-A)

2. Surgical management in women with endometriosis-related pain should be reserved for those in whom medical treatment has failed. (III A)

3.Surgical treatment of deeply infiltrating endometriosis may require particular experience with a multidisciplinary approach. (III-A)

4. Ovarian endometriomas greater than 3 cm in diameter in women with pelvic pain should be excised if possible. (I-A)

5. In patients not seeking pregnancy, therapy with CHCs (cyclic or continuous) should be considered after surgical management of ovarian endometriomas. (I-A)

6. Presacral neurectomy may be considered as an adjunct to the surgical treatment of endometriosis-related pelvic pain.(I-A)

Chapter 5. Surgical Management of Infertility Associated With Endometriosis

Summary Statements

1. Laparoscopic treatment of minimal or mild endometriosis improves pregnancy rates regard less of the treatment modality. (I)

2. The effect on fertility of surgical treatment of deeply infiltrating endometriosis is controversial. (II)

3. Laparoscopic excision of ovarian endometriomas more than 3 cm in diameter may improve fertility. (II)

Chapter 6: Medical Treatment of Infertility Related to  Endometriosis

Summary Statement

1. If a patient with known endometriosis is to undergo IVF, GnRH agonist suppression with HT addback for 3 to 6 months before IVF is associated with an improved pregnancy rate. (I)

Recommendation

1. Medical management of infertility related to endometriosis in the form of hormonal suppression is ineffective and should not be offered. (I-E)

Chapter 7: Endometriosis in Adolescents

Summary Statements

1. Endometriosis is the most common cause of secondary dysmenorrhea in adolescents. (II-2)

2. Adolescents with endometriosis are more likely than adult women to present with acyclic pain. (III)

3. The physical examination of adolescents with endometriosis will rarely reveal abnormalities, as most will have early-stage disease. (II-2)

Recommendations

1. Endometriosis in adolescents is often early stage and atypical. Laparoscopists should look intra abdominally for clear vesicles and red lesions in adolescents. (II-2B)

2. All available therapies for endometriosis may be used in adolescents, but the age of the patient and the side-effect profiles of the medications should be considered. (III-A)

Chapter 8: Endometriosis and Cancer

Summary Statements

1. The prevalence of ovarian cancer in patients with endometriosis is under 1%. (II-2)

2. Excision or sampling of suspected endometriosis lesions and endometriomas helps con firm the diagnosis and exclude underlying malignancy. (II-2)

Recommendations

1. Biopsy of endometriosis lesions should be considered to confirm the diagnosis and to rule out underlying malignancy. (II-2A)

2. Suspected ovarian endometriomas should be treated according to the SOGC guide line “Initial Evaluation and Referral Guidelines for Management of Pelvic/Ovarian Masses.” (III-A).