31 May 2021

Red flags for endometriosis

Clinical Fertility Women

Persistent pelvic pain, fatigue and infertility are potential red flags for the common inflammatory condition endometriosis, according to the authors of new clinical guidelines.

Endometriosis – which involves cells similar to the endometrial-like cells growing outside the uterus – affects roughly one in nine women and girls, and accounted for 34,200 hospitalisations in Australia in 2016–2017.

Despite this, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists president Dr Vijay Roach noted in the foreword, it often went undiagnosed and this was the first Australian guideline for the condition and the related adenomyosis.

The expert working group who led the guidelines urged clinicians to watch for persistent pelvic pains, fatigue and infertility.

“These symptoms are not specific to endometriosis and there are many causes of each symptom. This guideline reviews the evidence around endometriosis as a cause for these symptoms, rather than all types of pelvic pain or infertility,” they wrote.

They recommended suspicion of endometriosis in patients – including those under 17 years – who presented with one or more of: persistent pelvic pain; dysmenorrhoea affecting daily activities and quality of life; deep pain during or after sexual intercourse; period-related or cyclical gastrointestinal symptoms, in particular, painful bowel movements; period-related or cyclical urinary symptoms, in particular, blood in the urine or pain passing urine or infertility in association with one or more of the above.

“A clinical pelvic examination is an important part of an initial assessment to investigate suspected endometriosis – consider offering a pelvic examination or, if this is not appropriate, an abdominal examination,” they said.

Transvaginal ultrasound should be considered to investigate suspected endometriosis even if the pelvic and/or abdominal examination was normal, and to identify endometriomas.

For people with suspected deep endometriosis involving the bowel, bladder, or ureter, they recommended considering a detailed pelvic ultrasound or MRI before operative laparoscopy. Laparoscopic surgery may be considered to diagnose and treat people with suspected endometriosis, even if the ultrasound was normal, they added.

They recommended against the use of serum biomarkers such as CA125, pelvic MRI or computed tomography (CT) as the primary investigation tool for diagnosis. But MRI, or CT if MRI was not available, could be considered to assess the extent of deep endometriosis involving the bowel, bladder or ureter.

But a normal abdominal or pelvic examination, ultrasound, CT, or MRI did not exclude the possibility of endometriosis, they said.

“If clinical suspicion remains or symptoms persist, consider referral for further assessment and investigation.”

Download the guideline here.

COVID-19 live update