What are the ACOG recommendations for diagnosing and managing endometriosis?

ACOG Recommendations for Endometriosis: Diagnosis and Management

Diagnosis

Histologic examination should confirm the presence of endometrial lesions, especially those with non-classical appearance, though experienced surgeons familiar with the protean appearances of endometriosis may rely on visual inspection alone. 1

Clinical Presentation

• Pain patterns fall into three specific categories: secondary dysmenorrhea (pain commencing before menstrual onset), deep dyspareunia exaggerated during menses, and sacral backache with menses 1, 2
• The depth of endometriosis lesions correlates with pain severity, though pain has little relationship to the type of lesions seen by laparoscopy 1, 2
• Chronic non-menstrual pelvic pain lasting at least six months outside the menstrual cycle indicates possible endometriosis 2

Diagnostic Approach

• Peritoneal biopsy should be used to diagnose questionable peritoneal lesions 1, 3
• Transvaginal ultrasound and MRI are valuable for detecting endometriotic cysts and deep infiltrating lesions 4, 5
• Serum CA-125 has limited utility as a diagnostic marker, particularly in mild or minimal disease 1
• If endometriosis is suspected based on clinical symptoms but imaging is negative or empirical treatment is ineffective, refer to a gynecologist for laparoscopy 4

Medical Management

First-Line Treatment

NSAIDs are the recommended first-line approach for immediate pain relief. 3, 6

Second-Line Hormonal Therapies

Combined oral contraceptives provide effective pain relief compared to placebo and may be equivalent to more costly regimens, with Category 1 classification (no restrictions) for women with endometriosis. 3, 6

• Progestins (oral norethindrone 0.35 mg daily or depot medroxyprogesterone acetate) are effective alternatives with similar efficacy to other hormonal treatments 3, 6
• The 52mg levonorgestrel-releasing intrauterine system is recommended as first-line hormonal therapy 7

Third-Line Treatment

For pain relief, treatment with a GnRH agonist for at least three months or with danazol for at least six months appears equally effective in most women. 1

• GnRH agonists (leuprolide 3.75 mg IM monthly or 11.25 mg every 3 months) provide the most robust pain relief for severe endometriosis 6
• When using GnRH agonists long-term, add-back therapy (norethindrone acetate 5 mg daily with or without low-dose estrogen) must be implemented to reduce or eliminate bone mineral loss without reducing pain relief efficacy. 1, 3, 6

Critical Limitations

• No medical therapy has been proved to eradicate endometriosis lesions completely 1, 6
• There is no evidence that medical treatment affects future fertility in women with endometriosis 1

Surgical Management

Surgery provides significant pain reduction during the first six months following the procedure, though up to 44% of women experience symptom recurrence within one year. 1, 3, 6

Indications for Surgical Referral

• Medical treatment alone may not be sufficient for severe endometriosis 3, 6
• Empirical therapy is ineffective 2
• Immediate diagnosis is necessary 2
• Patient desires pregnancy 2
• Laparoscopic approach is recommended for surgical treatment 7

Post-Surgical Management

• After surgery when pregnancy is not desired, a combined hormonal contraceptive or 52mg levonorgestrel-releasing IUS is recommended as first-line treatment 7
• Hormone replacement therapy with estrogen is not contraindicated following hysterectomy and bilateral salpingo-oophorectomy for endometriosis 3

Pain Crisis Management

Acute Pharmacologic Interventions

• Limit ketorolac use to maximum 5 days due to gastrointestinal and renal risks 6
• Tramadol 50-100 mg every 6 hours is an alternative with superior efficacy to naproxen for endometriosis pain 6
• Transition to oral NSAIDs: naproxen 550 mg twice daily or ibuprofen 600-800 mg three times daily 6

Adjunctive Non-Pharmacologic Measures

• Heat application to abdomen or back may reduce cramping pain 6
• Acupressure on Large Intestine-4 (LI4) or Spleen-6 (SP6) points may help reduce cramping pain 6
• Aromatherapy with lavender may increase satisfaction and reduce pain or anxiety 6

Multidisciplinary Approach

In the event of failure of initial treatment, recurrence, or multiorgan involvement, a multidisciplinary team meeting is recommended involving physicians, surgeons and other professionals. 7

Important Caveats

• The correlation between symptoms and stage of endometriosis is poor 5, 8
• Endometriosis affects approximately 2-10% of women of reproductive age worldwide 2
• Patients with endometriosis have a 16-34% increased risk of stroke and should undergo vascular risk factor evaluation and modification 2
• Antigonadotrophic hormonal therapy is not recommended for patients with endometriosis and infertility to increase chances of spontaneous pregnancy 7