Endometriosis is a common condition characterised by the growth of ectopic endometrial tissue outside of the uterine cavity. Around 10% of women of reproductive age have a degree of endometriosis.

Clinical features

• chronic pelvic pain
• secondary dysmenorrhoea
  • pain often starts days before bleeding
• deep dyspareunia
• subfertility
• non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
• on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen

Investigation

• laparoscopy is the gold-standard investigation
• there is little role for investigation in primary care (e.g. ultrasound)- if the symptoms are significant the patient should be referred for a definitive diagnosis

Management depends on clinical features - there is poor correlation between laparoscopic findings and severity of symptoms. NICE published guidelines in 2017:

• NSAIDs and/or paracetamol are the recommended first-line treatments for symptomatic relief
• if analgesia doesn't help then hormonal treatments such as the combined oral contraceptive pill or progestogens e.g. medroxyprogesterone acetate should be tried

If analgesia/hormonal treatment does not improve symptoms, or if fertility is a priority, the patient should be referred to secondary care. Secondary treatments include: