Intended for healthcare professionals

Clinical Review


BMJ 2014; 348 doi: (Published 19 March 2014) Cite this as: BMJ 2014;348:g1752
  1. Martha Hickey, professor of obstetrics and gynaecology1,
  2. Karen Ballard, senior lecturer in women’s health 2,
  3. Cindy Farquhar, professor of obstetrics and gynaecology3
  1. 1Department of Obstetrics and Gynaecology, University of Melbourne and the Royal Women’s Hospital, Melbourne, Victoria, Australia 3052
  2. 2Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
  3. 3Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
  1. Correspondence to: M Hickey Hickeym{at}

Summary points

  • Medical treatment is not recommended for women with endometriosis who are trying to conceive as it does not improve pregnancy rates and delays fertility

  • The combined oral contraceptive, oral or depot MPA (medroxyprogesterone acetate), and Mirena (levonorgestrel releasing intrauterine system) are as effective as the GnRH (gonadotrophin releasing hormone) analogues and can be used long term

  • When surgical treatment is being considered, attempt laparoscopic excision or ablation at the time of diagnostic laparoscopy when possible

  • The cyst wall of endometriomas should ideally be removed instead of drainage and ablation but treatment can lead to reduced ovarian reserve

  • In the five years after surgery or medical treatment, 20-50% of women will experience recurrence of symptoms

  • Long term medical treatment (with or without surgery) might reduce recurrence but more data are needed to define the optimum medical treatment

Endometriosis is a relatively common and potentially debilitating condition affecting women of reproductive age. Prevalence is difficult to determine, firstly because of variability in clinical presentation, and, secondly because the only reliable diagnostic test is laparoscopy, when endometriotic deposits can be visualised and histologically confirmed. Population based studies report a prevalence of around 1.5% compared with 6-15% in hospital based studies.1 Endometriosis can be asymptomatic, but those with symptoms generally present early in reproductive life and improve after menopause. Symptomatic endometriosis can result in long term adverse effects on personal relationships, quality of life, and work productivity. A European survey of nearly 1000 women indicated that the average annual cost per woman with endometriosis was nearly €1000 (£822, $1380) with two thirds of the costs from loss of productivity.2 The most important predictor of healthcare costs is decreased quality of life, and this is found to be greatest in women with pain, infertility, and persistent disease.3 We have described the clinical …

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