AKT · Obstetrics & gynaecology/Menstrual & benign gynae

Endometriosis

Ectopic endometrial tissue outside the uterus

Overview

Endometrial-like tissue outside the uterine cavity, responding to cyclical hormones — causing chronic pelvic pain, dysmenorrhoea, deep dyspareunia and subfertility. Laparoscopy is the gold-standard diagnostic.

Recognise

Cyclical chronic pelvic pain, secondary dysmenorrhoea (pain BEFORE/with menses)
Deep dyspareunia, dyschezia, cyclical bowel/bladder symptoms
Subfertility; fixed retroverted uterus, adnexal tenderness, uterosacral nodularity

Red flags

Severe pain, bowel/urinary involvement, fertility concerns → specialist referral

Differentials & how to tell them apart

Primary dysmenorrhoeapain only WITH menses from menarche, no signs/subfertility

PIDinfective, fever, discharge, cervical motion tenderness

IBSno cyclical pattern, bowel-predominant

Adenomyosisbulky tender uterus, often older/parous

Investigations

Transvaginal USS (endometriomas/deep disease) but a NORMAL scan does NOT exclude it. Laparoscopy = gold standard (chocolate cysts, powder-burn lesions).

Management

NSAID/paracetamol + hormonal suppression (COCP or progestogen)

1Analgesia (NSAID/paracetamol) + hormonal treatment: COCP or a progestogen (POP, implant, injectable or LNG-IUS).
2Refer to gynaecology if treatment fails, fertility is affected, or deep disease: GnRH analogues, laparoscopic excision/ablation.
3Subfertility: do not use hormonal suppression to improve fertility — refer for laparoscopic treatment/assisted conception.

NSAID / paracetamol — first-line analgesia

COCP or progestogen — hormonal suppression (first-line hormonal)

GnRH analogues — second-line, specialist (with add-back HRT)

Key points

A normal USS does not exclude endometriosis — refer on clinical suspicion. Hormonal treatment manages pain but does not improve fertility.

Monitor & prognosis

Pain, function, fertility.

Chronic, hormonally driven; improves after menopause.

Source: NICE NG73; CKS Endometriosis