Hum. Reprod. Advance Access originally published online on June 24, 2005
Human Reproduction 2005 20(10):2698-2704; doi:10.1093/humrep/dei135
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ESHRE PAGE |
ESHRE guideline for the diagnosis and treatment of endometriosis
1 University of Oxford, Oxford, UK, 2 Karolinska Institutet, Stockholm, Sweden, 3 Clinique Universitaire Baudelocque, Paris, France, 4 Leuven University, Leuven, Belgium, 5 Maastricht University, Maastricht, The Netherlands, 6 Muenster University Hospital, Muenster, Germany, 7 Endometriose Foreningen, Denmark, 8 University of Cambridge, Cambridge, UK and 9 University College Hospital, London, UK
10 To whom correspondence should be addressed at: Nuffield Department of Obstetrics and Gynaecology, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK. E-mail: skennedy{at}molbiol.ox.ac.uk
The objective was to develop recommendations for the diagnosis and treatment of endometriosis and its associated symptoms. A working group was convened comprised of practising gynaecologists and experts in evidence-based medicine from Europe, as well as an endometriosis self-help group representative. After reviewing existing evidence-based guidelines and systematic reviews, the expert panel met on three occasions for a day during which the guideline was developed and refined. Recommendations based solely on the clinical experience of the panel were avoided as much as possible. The entire ESHRE Special Interest Group for Endometriosis and Endometrium was given the opportunity to comment on the draft guideline, after which it was available for comment on the ESHRE website for 3 months. The working group then ratified the guideline by unanimous or near-unanimous voting; finally, it was approved by the ESHRE Executive Committee. The guideline will be updated regularly, and will be made available at http://www.endometriosis.org/guidelines.html with hyperlinks to the supporting evidence, and the relevant references and abstracts. For women presenting with symptoms suggestive of endometriosis, a definitive diagnosis of most forms of endometriosis requires visual inspection of the pelvis at laparoscopy as the ‘gold standard’ investigation. However, pain symptoms suggestive of the disease can be treated without a definitive diagnosis using a therapeutic trial of a hormonal drug to reduce menstrual flow. In women with laparoscopically confirmed disease, suppression of ovarian function for 6 months reduces endometriosis-associated pain; all hormonal drugs studied are equally effective although their side-effects and cost profiles differ. Ablation of endometriotic lesions reduces endometriosis-associated pain and the smallest effect is seen in patients with minimal disease; there is no evidence that also performing laparoscopic uterine nerve ablation (LUNA) is necessary. In minimal–mild endometriosis, suppression of ovarian function to improve fertility is not effective, but ablation of endometriotic lesions plus adhesiolysis is effective compared to diagnostic laparoscopy alone. There is insufficient evidence available to determine whether surgical excision of moderate–severe endometriosis enhances pregnancy rates. IVF is appropriate treatment especially if there are coexisting causes of infertility and/or other treatments have failed, but IVF pregnancy rates are lower in women with endometriosis than in those with tubal infertility. The management of severe/deeply infiltrating endometriosis is complex and referral to a centre with the necessary expertise is strongly recommended. Patient self-help groups can provide invaluable counselling, support and advice.
Key words: diagnosis/endometriosis/ESHRE guidelines/treatment
* The manuscript was prepared by the first author; all other authors contributed equally and are listed in alphabetical order. Guideline Development Group: Agneta Bergqvist, Karolinska Institutet, Stockholm (Chair), Charles Chapron, Clinique Universitaire Baudelocque, Paris (Working party), Gerard Dunselman, Maastricht University (Working party), Robert Greb, Muenster University Hospital (Working party), Thomas D’Hooghe, Leuven University (Vice-Chair), Lone Hummelshoj, Endometriose Foreningen, Denmark (Working party), Stephen Kennedy, University of Oxford (Report writer), Philippe Koninckx, Leuven University and University of Oxford (Contributor), Roberto Matorras, País Vasco University (Contributor), Michael Mueller, University of Berne (Contributor), Andrew Prentice, University of Cambridge (Working party), Ertan Saridogan, University College Hospital, London (Working party), Juan Garcia-Velasco, Instituto Valenciano de Infertilidad, Madrid (Contributor).
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