NICE publishes first guideline on endometriosis

NICE has published its first guideline on the diagnosis and management of endometriosis (NG73). The guideline aims to raise awareness of the symptoms of endometriosis, as well as provide advice on the action to take when patients with suspected endometriosis first present in healthcare settings. It also provides guidance on the treatment options available.

The guideline recommends setting up a managed clinical network for women with suspected or confirmed endometriosis, comprising of community services (including GPs, practice nurses and sexual health services), gynaecology services and specialist endometriosis services, in order to provide the best co-ordinated care.

NICE explains that endometriosis should be suspected in women presenting with chronic pelvic pain, dysmenorrhea affecting quality of life, dyspareunia, cyclical urinary symptoms or infertility. Signs to look for on abdominal/pelvic examination include reduced organ mobility and enlargement, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions.

For first-line management of endometriosis-related pain, a short trial (eg three months) of paracetamol or an NSAID, alone or in combination, should be considered. Hormonal treatment, such as the combined oral contraceptive pill or a progestogen, should also be offered to women with suspected, confirmed or recurrent endometriosis. However, hormonal treatment should not be offered to women who are trying to conceive.

Referral to gynaecology services should be considered if the patient has severe, persistent or recurrent symptoms of endometriosis, if they have pelvic signs of endometriosis or if first-line management strategies are not effective, not tolerated or contraindicated. Referral to a specialist endometriosis service is indicated if they have suspected or confirmed deep endometriosis involving the bowel, bladder or ureter.

Surgery (eg laparoscopic excision or ablation, and occasionally if indicated, hysterectomy), is another treatment option after discussion of the benefits and risks (including impact on fertility) and joint decision-making with the patient. Three months of treatment with a gonadotrophin-releasing hormone (GnRH) agonist should be considered as an adjunct to surgery for deep endometriosis involving the bowel, bladder or ureter. Following laparoscopic excision or ablation, hormonal treatment can be considered to prolong the benefits and help manage symptoms.

Within supplementary tools and resources, NICE includes a treatment algorithm for the management of patients with suspected endometriosis, as well as a patient decision aid on hormonal treatments for endometriosis symptoms.

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