REMEDY : BNSSG referral pathways

Endometriosis

Checked: 16-10-2017 by Rob.Adams Next Review: 16-10-2018

Introduction

The following is based on NICE Guideline NG73 (September 2017) and has been summarised by Dr Rachel Brown, GPSI in gynaecology.

Endometriosis affects approximately 10% of women and is one of the most common gynaecological disorders.Its symptoms are many and varied and at present it can only be diagnosed at laparoscopy.

Its precise cause is not yet clear but it is hormone mediated and is associated with menstruation.

There can often be a delay of 5-10 years between first reporting symptoms and confirmation of the diagnosis. Patient self-help groups eg Endometriosis UK, emphasise that healthcare professionals often do not recognise the importance of severe symptoms and therefore do not consider the diagnosis of endometriosis. Many women report that the delay in diagnosis leads to chronic pain and ill health and a possibly to a condition that is more difficult to treat.

Endometriosis should be considered in women and adolescents presenting with the following:

  • chronic pelvic pain

  • severe dysmenorrhoea

  • deep dyspareunia

  • cyclical gastrointestinal symptoms eg dyschezia

  • cyclical urinary symptoms eg haematuria & dysuria

  • infertility in association with 1 or more of the above.

It is important to distinguish pain symptoms that are associated specifically with endometriosis. Dysmenorrhea is very common and is usually managed successfully with analgesia, but in endometriosis, dysmenorrhea is often more severe, necessitating time off work despite analgesia. Severe, persistent, frequent symptoms should help to distinguish physiological from pathological pain associated with endometriosis in order to help GPs decide which women required further investigation.

 

Management in Primary Care

Investigations

Bimanual examination can sometimes identify several signs, such as reduced organ mobility and tender nodularity in the posterior vaginal fornix. However, a speculum examination is also essential to look for endometriotic vaginal lesions.

Both ultrasound and MRI are reliable tests for identifying site specific endometriosis. An ultrasound scan can accurately identify site specific endometriosis (eg endometrioma, rectovaginal and rectocervical disease). However if endometriosis is superficial and spread across different sites throughout the pelvis, ultrasound is less accurate. If an ultrasound is inconclusive or negative, but deep endometrioses involving the bowel, bladder or ureter are suspected then women might be referred for an MRI scan, normally once in secondary care. Do not exclude endometriosis if vaginal examination and ultrasound are normal. If clinical suspicion remains or symptoms persist, consider referral for further assessment and investigation.

Treatment

If endometriosis is suspected, then it is recommended that the first line treatment is with analgesia and contraceptive options in primary care, before the need to make a definite diagnosis. If a trial of paracetamol or an NSAID (alone or in combination) does not provide adequate pain relief, then stronger & other forms of pain management should be considered.

Hormonal treatments for endometriosis reduce or stop menstruation and reduce pain. They are contraceptive but have no effect on subsequent fertility after discontinuation. The first-line hormonal treatment would generally be the combined oral contraceptive pill or the levonorgestrel coil (LNG-IUS).They have good efficacy and their side effects are generally well tolerated. The evidence shows that conventional use of the combined oral contraceptive pill is effective, but continuous and tricycling of the pill are used in clinical practice. There is no evidence to support this but it is accepted as effective with limited adverse events. If first-line hormonal treatment is contraindicated or not tolerated, then women should be referred to a gynaecologist.

Pain is the commonest and most debilitating symptom of endometriosis. It can be cyclical pelvic pain, during menstruation, sometime starting before a period; some women suffer with constant pain. Referred pain to the back and legs is common. Women often also suffer with non-cyclical pain, deep dyspareunia, and pain associated with bowel and bladder functions. For many women, pain becomes persistent or chronic. There was no evidence to support the use of non pharmacological methods for pain relief but the use of patient support groups and specialist endometriosis nurses is likely to be of great benefit.

Referral Guidance

Referral should be considered based on the severity, persistence and recurrence of symptoms. If a clinical examination or investigation indicates pelvic signs of endometriosis, this should also lead to referral. Laparoscopy is the gold standard for making a diagnosis.

Locally, laparoscopic investigation is available at St Michaels Hospital, South Bristol Community Hospital, Southmead Hospital, Cossham Hospital and Emersons Green Treatment Centre. All referrals should be sent via e-referral to give patients a choice of provider.

If laparoscopy is normal then consider other causes of chronic pelvic pain and/or referral to pain clinic.

Red Flags

CKS has guidelines on when to suspect ovarian cancer

Suspect ovarian cancer and carry out tests:

1. In any woman (particularly if over 50 years of age), if any of the following symptoms are persistent or frequent (particularly more than 12 times per month):

 - Abdominal distension (bloating).

 - Feeling full (early satiety) or loss of appetite, or both.

 - Pelvic or abdominal pain.

 - Increased urinary urgency or frequency, or both.

2. In any woman over 50 years of age, if she has had symptoms suggestive of irritable bowel syndrome (IBS) within the last 12 months

3. Consider the possibility of ovarian cancer and consider carrying out tests in any woman who reports any of the following unexplained symptoms:

  • Weight loss.

  • Malaise or fatigue.

  • Change in bowel habit.