Endometriosis

Endometriosis is defined as the presence of endometrial like tissue outside the uterus , which includes a chronic , inflammatory reaction ( Kennedy et al 2005 )
Thought to affect 6 to 10 % of the general population.
Pathophysiology –Chronic estrogen or progestogen responsive inflammatory disease associated with pain symptoms and infertility 
( Barra F et al 2018 ) Other theories
○ retrograde menstruation
○ metaplasia
○ implantation theory
○ induction theory
○ immune dysfunction
○ stem cell 
○ genetics
○ apoptosis suppression and alteration of endometrial cell fate
When to suspect –chronic pelvic pain period related pain ( dysmenorrhoea ) affecting daily activities and QOL deep pain during or after sexual intercourse period-related or cyclical gastro-intestinal symptoms , in particular , painful bowel movements period related or cyclical urinary symptoms , in particular , blood in urine or passing urine infertility in association with 1 or more of above
Referral –they have severe , persistent or recurrent symptoms of endometriosis pelvic signs of endometriosis OR initial management is not effective , not tolerated or in contraindicated if they have suspected or confirmed deep endometriosis involving the bowel , bladder or uterus consider referring young women ( aged 17 & under ) with suspected or confirmed endometriosis
Management –Analgesia e.g paracetamol or NSAID or both Hormonal manipulation – suppress menstruation and suppress pain
contraceptive preparations e.g COCP
Progestogens
GnRH agonists – suppress ovarian activity and induce a hypo-oestrogenic state Laparoscopic surgery Emotional and psychological support

LINKS AND RESOURCES

PATIENT INFORMATION
PIL from Royal College of Obstetricians and Gynaecologists https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/gynaecology/pi-endometriosis.pdf
American College of Obstetricians and Gynecologists on endometriosis https://www.acog.org/Patients/FAQs/Endometriosis?IsMobileSet=false
Endometriosis UK a large charity provides information and support for patients with endometriosis – advise patients to look at the publications section which has some very useful leaflets https://www.endometriosis-uk.org/understanding-endometriosis
A global forum for news and information about endometriosis – https://endometriosis.org/
Pelvic Pain Support Network on Endometriosis https://www.pelvicpain.org.uk/conditions/endometriosis/
Endometriosis Foundation of America https://www.endofound.org/
INFORMATION FOR CLINICIANS
NICE guideline https://www.nice.org.uk/guidance/ng73

ACOG Updates Guideline on Diagnosis and Treatment of Endometriosis 2011 https://www.aafp.org/afp/2011/0101/p84.html

Diagnosis and management of endometriosis: a
systematic review of international and national
guidelines M Hirsch,a,b MR Begum,a E Paniz,
a C Barker,c CJ Davis,a JMN Duffyd,e https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/1471-0528.14838
A vast collection of all guidelines from Geneva Foundation for Medical EducationResearch https://www.gfmer.ch/Guidelines/Gynecology/Endometriosis.htm
References

1. Endometriosis : diagnosis and management NICE Guideline 73 September 2017
2. ESHRE Management of women with endometriosis : Guideline of the European Society of Human Reproduction and Embryology Sept 2013


3. Endometriosis: implications of new guidelines for general practice Dr Jessica Garner British Journal of Family Medicine, 6 (1), January, 2018 BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3935 (Published 06 September 2017)
4.  Theories on the Pathogenesis of Endometriosis International Journal of Reproductive Medicine
   Volume 2014, Article ID 179515, 9 pages http://dx.doi.org/10.1155/2014/179515
5. Expert Opin Drug Metab Toxicol. 2018 Apr;14(4):399-415. doi: 10.1080/17425255.2018.1461840. Epub 2018 Apr 10.Current understanding on pharmacokinetics, clinical efficacy and safety of progestins for treating pain associated to endometriosis.