Evaluation and Treatment of Endometriosis

SYNOPSIS:

Endometriosis is a chronic condition that results in infertility and chronic pain. Clinical manifestations vary and are not good predictors of the severity of the disease. Dysmenorrhea, chronic pain, dyspareunia, uterosacral ligament nodularity, and adnexal masses are among the common presentations. Evaluation has shifted toward symptom-based clinical diagnosis to reduce delays in care. Treatment is aimed at optimizing pregnancy rates and minimizing symptoms.

KEY POINTS:

Symptoms

• Dysmenorrhea
• Chronic pelvic pain (cyclical and non-cyclical)
• Dyspareunia
• Uterosacral ligament nodularity
• Adnexal masses
• Bowel and bladder symptoms, such as dyschezia, hematochezia, hematuria, dysuria (may be cyclical)
• Adolescent considerations
  • Recurrent school absenteeism
  • Nausea with pelvic pain
• Infertility associated with any of the above signs or symptoms
• Fatigue is often reported
• Extra abdominal endometriosis
  • Shoulder tip pain
  • Catamenial pneumothorax
  • Cyclical chest pain and cough and hemoptysis
  • Cyclical scar swelling and pain

NOTE: Symptoms do not correlate with severity of disease

Diagnosis

• Clinical diagnosis is acceptable to reduce treatment delay and begin treatment
  • Symptom-based assessment and/or physical examination
• Laparoscopy
  • Consider diagnostic laparoscopy for confirmation but not required to initiate empiric medical treatment
    • If performed, a biopsy of suspected lesions should be considered
    • Negative histology does not rule out a diagnosis of endometriosis
  • Lesion colors
    • Black powder-burn, red or white | Often clear or red in adolescents
• Biomarkers
  • Strong recommendation against use of biomarkers for diagnostic purposes

Imaging

• Transvaginal ultrasonography (TVUS)
  • Recommended initial imaging modality for the evaluation of all clinically suspected endometriosis, even in the absence of an adnexal mass
  • TVUS is the technique of choice in differentiating an endometrioma from other adnexal masses, and in detecting deeply infiltrating endometriosis of the rectum or rectovaginal septum
• MRI
  • Helpful for the identification of deep endometriosis

Treatment

Medical Management

• Pain associated with endometriosis can be reduced with use of
  • Progestins | Combined oral contraceptives (OCs) | Nonsteroidal anti-inflammatory drugs | Gonadotropin-releasing hormone (GnRH) agonists | Aromatase inhibitors
  • Extended cycle OCs or continuous OCs can be used to limit dysmenorrhea and reduce recurrence of endometriomas
  • The levonorgestrel IUD is effective in reducing pelvic pain related to endometriosis
• GnRH agonists
  • ‘Add back’ therapy reduces side effects and bone loss and may include (1) progestins alone, (2) progestins and bisphosphonates, or (3) low dose progestins and estrogens
  • There is no difference between GnRH agonists and other medical treatments for endometriosis based on a recent Cochrane review | Typically not be used as a primary treatment
• GnRH antagonists have been approved by the FDA approved for management of moderate to severe pain associated with endometriosis
  • Elagolix (see below for prescribing information)
  • Relugolix (in combination with estradiol, and norethindrone acetate; see below for prescribing information)

Non-pharmacological Management

• Pelvic physiotherapy
  • Some reports of benefit
  • Most studies included medical management
• Cognitive behavioral therapy (CBT)
  • Used for chronic pain

Surgical Management

• Excision of endometriomas can improve pregnancy rates
• Drainage and ablation of cyst is less effective
• Patients undergoing surgery for removal of endometriosis should be counseled that there is a chance of requiring further surgery
• Hysterectomy
  • Limited high level evidence studies                 
  • Typically offered to women who do not desire future fertility
  • Not a “cure” and may be of greatest benefit for women with adenomyosis or not responding to more conservative treatments
  • Recent studies question the benefit of bilateral salpingo-oopherectomy (BSO)
  • For women also undergoing BSO, hormone therapy should be started following surgery
    • Hormone therapy with estrogen is not contraindicated after hysterectomy with BSO

Learn More – Primary Sources:

ACOG Clinical Practice Guideline 11: Diagnosis of Endometriosis

ASRM: Endometriosis Resource Center

BMJ State of the Art Review: Pathophysiology, diagnosis, and management of endometriosis

Optimal Management of Endometriosis and Pain

Endometriosis: Where Are We and Where Are We Going?

Gastrointestinal and Urinary Tract Endometriosis: A Review on the Commonest Locations of Extrapelvic Endometriosis

FDA: HIGHLIGHTS OF PRESCRIBING INFORMATION for ORILISSA (Elagolix)

FDA: HIGHLIGHTS OF PRESCRIBING INFORMATION for MYFEMBREE (Relugolix)