Endometriosis

doi:10.1136/bmj.323.7304.93

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Andrew Prentice (ap128@cam.ac.uk), senior lecturer

University Department of Obstetrics and Gynaecology, Rosie Hospital, Cambridge CB2 2SW

Many doctors, both general practitioners and specialists, find endometriosis difficult to manage. Equally, many patients are dissatisfied with the care they receive. Endometriosis is the presence of endometrium at sites outside the endometrial cavity. It has long been known that the symptoms experienced by a patient may seem disproportionate to the extent of the disease observed within that patient's pelvis. For the patient it is not the endometriosis that is important but rather the illness that they experience. In this article I address the treatment of symptomatic endometriosis and infertility associated with the disease.

Summary points

Endometriosis is a common cause of pelvic pain

The disease is difficult to diagnose because patients may present with a variety of symptoms

In primary care first line management should include non-steroidal anti-inflammatory drugs and the combined oral contraceptive

Referral is indicated when first line management fails or infertility is a problem

Controversy exists over the precise role of surgery and further evidence is required

Methods

This review is based on information from the controlled trials register of the Cochrane Library and the personal experience of the author.

Managing symptomatic endometriosis

Patients with endometriosis may present with many different symptoms. The most common symptom is dysmenorrhoea. Often the patient presents when the dysmenorrhoea increases in severity. Dysmenorrhoea may precede the onset of menstruation. Endometriosis is the underlying cause in 15% of cases of pelvic pain.1 The variety of symptoms and their different presentations lead to difficulties in diagnosing the condition. In addition to pain the patient may present with the non-specific symptoms of fatigue, general malaise, and sleep disturbance. Some of the symptoms associated with endometriosis are listed in the box.

Diagnostic difficulty

A recent survey by the National Endometriosis Society (a support organisation for patients in the United Kingdom) of over 200 patients with a proved diagnosis of endometriosis highlighted …