Introduction
Background
1. Prevalence
2. Risk factors
1) Clinical factors
4) Dietary factors
Diagnosis
1. Symptoms
Clinicians should suspect endometriosis when patients complain of following symptoms; gynecologic symptoms — such as dysmenorrhea, non-cyclic pelvic pain, dyspareunia, infertility and fatigue accompanied any symptom of above, or cyclic non-gynecologic symptoms such as — dyschezia, dysuria, hematuria and rectal bleeding, and shoulder pain in reproductive age (grade D).
2. Clinical examination
Clinicians should perform pelvic and abdominal examination to all suspected endometriosis patients. When vaginal exam is not appropriate, as for a patient with no sexual intercourse history, a rectal examination may be performed instead for diagnosis (grade D).
Painful rectovaginal induration/nodule, and vaginal nodules in posterior vaginal fornix, may be due to deep endometriosis (grade C).
Clinicians may regard palpable ovarian mass in pelvic examination as an ovarian endometrioma (grade C).
Clinicians may consider endometriosis even if the patients have no abnormality in pelvic exam (grade C).
3. Laparoscopy
Histologic proof of endometriosis through laparoscopy is the gold standard of endometriosis diagnosis. Although laparoscopy without pathologic confirmation has limited value, the absence of histologic confirmation cannot exclude endometriosis (grade D).
KSE recommends biopsy and histologic confirmation when patient have endometrioma and/or deep endometriosis to exclude malignancy (grade D).
4. Ultrasound
KSE recommends transvaginal or transrectal ultrasonography to confirm or exclude ovarian endometriomas (grade A).
In premenopausal women, ovarian endometrioma has ultrasonographic findings, ground grass echogenicity, 1 to 4 compartments, absence of papillary structure, and blood flow (grade D).
Transvaginal or transrectal ultrasonography may be helpful for patient with rectal endometriosis related signs and/or symptoms to confirm or exclude endometriosis (grade A).
5. Magnetic resonance imaging
Clinicians should decide on follow-up assessment through additional imaging evaluation including magnetic resonance imaging (MRI), when deep endometriosis infiltrating ureter, bladder, or bowels is suspected in patients' history and clinical examination (grade D).
It is not yet verified yet that MRI is useful for diagnosis of peritoneal endometriosis (grade D).
Infertility
KSE recommends the removal of adhesions by excision or ablation of endometriosis lesion to improve spontaneous pregnancy rates for laparoscopically diagnosed minimal endometriosis (American Society for Reproductive Medicine [ASRM] stage 1, 2) for infertile women (grade A).
In infertile women with severe endometriosis (ASRM stage 3, 4), operative laparoscopy shows higher spontaneous pregnancy rate than expectant management (grade A).
KSE recommends ovarian cystectomy, instead of drainage and/or coagulation, because it may improve spontaneous pregnancy rate (grade A).
Ovarian function may decline after an operation for ovarian endometrioma (grade D).
When the patient wants to conceive naturally right after operation, clinicians should not prescribe adjuvant hormonal treatment (grade A).
Clinicians should not suppress ovarian function by hormonal treatment to improve fertility, in infertile women having endometriosis (grade A).
Clinicians should try assisted reproductive technology (ART) to infertile women with endometriosis, when causes of infertility are the compromised tubal function and/or male factor. It may be attempted, if patient has already failed to other infertility management (grade D).
Clinicians may consider controlled ovarian stimulation followed by intrauterine insemination in infertile women with ASRM stage 1, 2 endometriosis women (grade C).
In infertile women with severe endometriosis (ASRM stage 3, 4), in vitro fertilization-embryo transfer (IVF-ET) is an effective alternatives, if the patient have trouble conceiving after operation, or is of old age (grade C).
KSE recommends the use of GnRH agonists for 3-6 months before ART to improve fertility in women with infertility diagnosed with endometriosis (grade B).
In infertile women with endometrioma (≥3 cm), there is lack of evidence to support whether cystectomy prior to ART increase pregnancy rate (grade A).
KSE does not recommend supplying specific nutrients or applying alternative medicine to infertile women with endometriosis. However some women may feel that these treatments would be helpful (grade D).
It is possible the there is an increased incidence of spontaneous abortion, preterm delivery, small for gestational age (SGA), or placenta previa, when the mother has endometriosis in pregnancy (grade B).
Medical treatment of endometriosis-associated pain
There is no evidence that one medication has superior over any other medications, for endometriosis-associated pain treatment (grade A).
1. Empirical treatment
2. Combined oral contraceptives
Clinicians may prescribe combined oral contraceptives for endometriosis related pain control (grade B).
Continuous use of combined oral contraceptives has advantages for pain relief compare to cyclic medication (grade C).
3. Progestins
KSE recommends progestin, such as medroxyprogesterone acetate (MPA), dienogest, or norethisterone acetate for endometriosis-associated pain (grade A).
Clinicians may use levonorgestrel intrauterine system (LNG-IUS) for endometriosis-associated pain (grade B).
4. GnRH agonist
KSE recommends GnRH agonist for treatment of endometriosis related pain (grade A).
Clinicians should prescribe add back therapy for minimizing disadvantages of low estrogen symptom (grade A).
Various medications, such as progestin, estrogen, estrogen+progestin, tibolone, etc. may use as add-back therapy. More studies are needed regarding which medication is most appropriate (grade C).
5. Other medications
Danazol, and gestrinone are effective for endometriosis related pain, but clinicians should be aware of the side effects (grade C).
GnRH antagonists are not appropriate for common use (grade C).
Clinicians may consider aromatase inhibitor merging with other medication; such as Combined oral contraceptive (COC), progestin, and GnRH agonist, when usual therapy is not satisfactory (grade B).
Surgical treatment of endometriosis
1. Targets for surgical treatment of endometriosis
Asymptomatic patients whose endometriosis was incidentally discovered during operation, do not need medical or surgical treatment (grade D).
Surgical management of endometriosis for endometriosis-related pain may be done after failure of medical treatment (grade D).
2. Evaluation before operation
Decision for surgical management of endometriosis should be based on clinical evaluation, imaging modality, and medical treatment response. Diagnostic laparoscopy should be restricted (grade D).
Imaging evaluation should be based on symptoms and physical examination (grade D)
Diagnostic value of preoperative serum CA125 is limited. Therefore, usual examination of serum CA125 is not recommended before operation. But, it may be done as a part of evaluation for undiagnosed adnexal mass (grade D).
3. Surgical approach
Clinicians should not prescribe hormonal treatment for endometriosis pain control before surgery (grade A).
Adjunctive hormonal therapy after surgery is divided into short-term (<6 months) and long-term (>6 months), and the latter is intended for secondary prevention (grade D).
Clinicians are recommended not to prescribe adjunctive short-term hormonal therapy for endometriosis associated pain after surgery, because it does not add to the outcome of surgery (grade A).
The selection of adjunctive treatment for prevention of recurrence and pain depends on patient preference, cost, efficacy and side effects (grade D).
4. Results of surgical treatment
Surgical removal of laparoscopically diagnosed endometriosis can be helpful for pain relief (grade A).
KSE recommends surgical resection of ovarian endometrioma, because it is more efficient to prevent pain recurrence than drainage or coagulation (grade A).
If the patient has finished child bearing, and not responsive to conservative management, clinicians may operate total hysterectomy and both salpingo-oophorectomy, and surgical removal of endometriosis. However, clinicians should explain that total hysterectomy is not essential for the treatment of endometriosis (grade D).
KSE recommends continuously prescribing combined estrogen/progestogen or tibolone (grade C).
Laparoscopy is preferred to laparotomy for surgical treatment of endometriosis (grade C).
Clinicians may use anti adhesion agents during endometriosis-related operation (grade B).
When patients have re operation for recurrent endometriosis, endometriosis is recurred in 20-40% of cases, similar to the recurrence rate after the first operation (grade A).
Clinicians should carefully consider repeating the operation, for the degree of pain relief after operation is significantly decreased when operation is repeated (grade C).
Although there is insufficient evidence, follicular phase may be beneficial for endometriosis operation (grade D).
5. Deep infiltrative endometriosis
6. Ovarian endometrioma
Clinicians should consider the patient's future plans for children when deciding on the therapeutic range of ovarian endometrioma (grade D).
Ovarian endometrioma may implicate the widespread endometriosis (grade D).
In women with ovarian endometrioma, KSE recommends cystectomy compared to drainage or CO2 laser vaporization. Ovarian cystectomy reduces pain and recurrence, and allows histological diagnosis (grade A).
Clinicians should remove ovarian endometrioma (≥3 cm) in women with pelvic pain (grade A).
Clinicians should prescribe post-operative hormone therapy for women who do not plan on pregnancy (grade A).
Clinicians should prescribe LNG-IUS, COC, or progestin at least 18-24 months after operation (grade A).
7. Additional treatment
KSE does not recommend laparoscopic uterosacral nerve ablation (LUNA) as an additional step to conservative surgery for endometriosis associated pain (grade A).
Clinicians can perform presacral neurectomy (PSN) for endometriosis associated midline pain as additional procedure to conservative surgery. It is effective, but risky and requires high degree skill (grade A).
Recurred endometriosis
Clinicians should avoid second line surgery in women who want to conceive when endometriosis is recurred after the first surgery (grade B).
Clinicians may try empirical hormonal treatment for recurrent endometriosis-related pain between in vitro fertilization (IVF) procedure cycles (grade D).
Asymptomatic endometriosis
It is unnecessary to remove incidentally-diagnosed peritoneal, ovarian, deep endometriosis (grade D).
Endometriosis of adolescents
Generally, treatment of adolescents' endometriosis is based remedy of adults (grade D).
Clinicians should be aware of loss of bone density, when prescribing GnRH agonist to adolescents (grade D).
Endometriosis in menopausal women
Endometriosis may exist after natural or surgical menopause, but symptoms usually disappear (grade D).
Endometriosis and ovarian cancer
Clinicians should confirm pathologic diagnosis after operative treatment.
KSE does not recommend additional evaluation for ovarian cancer in women with endometriosis, because the incidence of ovarian cancer is very low (grade A).