Updated Endometriosis Guidelines: Effective Treatments & Insights

What Do Updated Endometriosis Guidelines Mean to You?

A variety of treatments are available for endometriosis and its symptoms. They include pharmacological treatments, surgical treatments, acupuncture, electrotherapy, nutritional changes, psychological therapies and of course, pelvic floor physical therapy.

The World Health Organization (WHO) states that Endometriosis affects 190 million (10%) of women of reproductive age worldwide. It occurs when uterine-like tissue (similar to, but not the same as) grows outside of the uterus. Currently there is no known cause or cure, however various treatments exist to manage symptoms. Currently, diagnosis of endometriosis can be delayed up to 8-10 years after initial symptoms onset. This happens for a variety of reasons, including limited access to health care or knowledgeable practitioners, poor awareness of or minimization of symptoms.  In addition to the potentially debilitating symptoms of endometriosis, the socioeconomic cost of this disease is comparable to those of other chronic diseases such as diabetes mellitus.

Common Endometriosis symptoms include:

•       Dysmenorrhea (Painful menstrual periods)
•       Chronic pelvic pain
•       Infertility
•       Dyspareunia (painful intercourse)
•       Dysuria (painful or difficult urination)
•       Dyschezia (painful or difficult bowel movements)
•       Heavy menstrual bleeding
•       Pelvic inflammatory disease
•       Irritable bowel syndrome
•       Fibrocystic breast disease

Retrospectively, studies show the more symptoms one has, the increased likelihood of endometriosis.

Most recently, the ESHRE (European Society of Human Reproduction and Embryology) has updated some guidelines for some approaches to diagnosing and treating those with endometriosis.

A faster diagnosis and therefore earlier treatment will likely increase quality of life, decrease overall costs of managing the disease and potentially manage the progression of the disease. Although the gold standard for diagnosis has always been a laparoscopic evaluation (and excision to remove it), ESHRE is suggesting diagnosing endometriosis prior to laparoscopy to begin treatment sooner in individuals suffering from the symptoms. 

Clinical evaluation is recommended, and some imaging techniques (MRI and ultrasound) have been found to have increasing efficacy detecting only some types of endometriosis. This isn’t to suggest one shouldn’t get laparoscopic confirmation; laparoscopy should be discussed with your doctor considering access to experienced practitioners, availability to financial/insurance resources and operative risks to the individual.  

Updates for treatment for endometriosis pain

• Gonadotropin Releasing Hormone (GnRH) agonist and/or antagonist are recommended for pain control since endometriosis is a hormone driven condition. There is no evidence that these medications negatively affect disease progression. Attention to fertility concerns must be addressed when taking these medications.
• NSAIDs may be offered to reduce endometriosis-associated pain. There is no evidence NSAIDs influence disease progression. Attention must be given to possible gastrointestinal or fertility side effects, particularly if taken continuously.

Updates for Endometriosis Treatments for Infertility

• Use of GnRH agonist for 3-6 months to downregulate ovarian function to improve fertility, including assisted techniques like in vitro fertilization is no longer recommended due to unclear benefits.
• Use of the Endometriosis Fertility Index (EFI) may be used pre or post-surgery to help determine with your provider fertility management options, assisted reproduction technologies or surgery.

Updates to Prevent Endometriosis Recurrence

In the literature, recurrence varies from 0%-89.6% which varies due to a variety of factors including the definitions of recurrence, length of follow up, study design, stage of the disease etc. Risk factors for recurrence include surgery related factors and personal factors (family history, age at surgery).

• Hormone treatments are recommended with hormonal contraceptives for at least 18-24 months after surgery to prevent recurrence.
• Assisted reproduction technologies doesn’t increase recurrence in those with deep endometriosis.
• When considering surgery, discuss with your doctor: “When surgery is indicated in women with an endometrioma, clinicians should perform ovarian cystectomy, instead of drainage and electrocoagulation, for the secondary prevention of endometriosis-associated dysmenorrhea, dyspareunia, and nonmenstrual pelvic pain. However, the risk of reduced ovarian reserve should be taken into account.”

Considerations/Updates Regarding Endometriosis in Adolescence:

Symptoms/conditions to alert you of the possibility of endometriosis in adolescence include:

•       Family history of endometriosis
•       Obstructive genital malformations
•       Early onset of menstruation
•       Short menstrual cycle

Be attentive to missed school or activities in a cyclical pattern or necessity for oral contraceptives for dysmenorrhea (painful periods).

We are part of a multidisciplinary team to help with the symptoms of endometriosis. Our therapists care about improving your quality of life and helping to reach your goals, whether it be reducing bladder pain, having painfree intercourse or reducing your cyclic and noncyclic pain. We also look at managing your pain from a whole body lens, understanding how one pain begets more pain. Give us a call or message us to schedule today.

 References:

1. https://www.who.int/news-room/fact-sheets/detail/endometriosis
2. Kalaitzopoulos DR, Samartzis N, Kolovos GN, Mareti E, Samartzis EP, Eberhard M, Dinas K, Daniilidis A. Treatment of endometriosis: a review with comparison of 8 guidelines. BMC Womens Health. 2021 Nov 29;21(1):397. doi: 10.1186/s12905-021-01545-5. PMID: 34844587; PMCID: PMC8628449.
3. 2022 ESHRE (European Society of Human Reproduction and Embryology) Endometriosis Guideline Development Group. www.eshre.eu/guidelines