GPAtlas
ENDOMETRIOSIS
gpatlas.co.uk
🔍 When to Suspect
One or more of: chronic pelvic pain (≥6 months), severe dysmenorrhea impacting daily life, deep dyspareunia, cyclical bowel/bladder symptoms, or infertility
🩺 Assessment
- ◉ Symptoms + triggers → Chronic pelvic pain, severe dysmenorrhea, deep dyspareunia, cyclical bowel symptoms (painful defecation, bloating) or urinary symptoms
- ◉ Risk factors/history → Family history of endometriosis, infertility, heavy/irregular periods
- ◉ Impact + mimics → Significant impact on quality of life, work, relationships, mental health; mimics include PID, IBS, interstitial cystitis
- ◉ Exam findings → Abdominal exam for masses; pelvic exam may reveal pelvic tenderness, a fixed/retroverted uterus, or nodules in the posterior fornix
💊 Management
🔸Key tests:
➤ Transvaginal ultrasound is first-line to look for endometriomas and rule out other causes; laparoscopy – specialist-only, no longer a routine prerequisite; a negative laparoscopy does not exclude endometriosis
🔸Lifestyle:
➤ Encourage keeping a symptom diary; consider pain management programs, physiotherapy, and psychological support (CBT)
🔸Pharmacological:
➤ First-line Analgesia: NSAIDs (e.g., naproxen) or paracetamol
➤ First-line Hormonal Treatment: Trial of CHC or progestogen-only method (POP, implant, injection, or IUS-Mirena) for 3-6 months
➤ Second-line Hormonal Treatment: GnRH agonists (e.g., goserelin) with HRT add-back therapy → Specialist-initiated
🔸Follow-up/safety-net:
➤ Review after 3 months to assess treatment response; signpost to support groups like Endometriosis UK
⚠️ Red Flags
• Red flags relate to ruling out other pathology, not specific to endometriosis itself
• Suspected ovarian cancer (persistent bloating, early satiety, pelvic pain)
• Signs of cervical cancer (post-coital or intermenstrual bleeding)
• Severe, acute pelvic pain suggesting ovarian torsion or rupture
➡️ Referral Criteria
Urgent: If acute severe pain or red flags for other conditions are present; refer via 2WW if malignancy is suspected
Routine: Refer to gynaecology if initial management fails, for definitive diagnosis, or if fertility is a concern; refer all young people (aged 17 and under)
📌 GP Tips
🔹A normal examination and a normal ultrasound scan do not rule out endometriosis; maintain clinical suspicion based on symptoms
🔹Treating empirically with hormonal contraception for 3-6 months is a reasonable diagnostic and therapeutic trial