Published 11 July 2022
ESHRE’s first update since 2013 on its endometriosis guideline represents a major shift in use of keyhole surgery for diagnosis and treatment of this chronic disease, which affects millions of women worldwide. Endometriosis in adolescents is covered for the first time.
Laparoscopy should no longer be the diagnostic gold standard in endometriosis but recommended only in certain patients, according to a new best practice guideline on endometriosis, the details of which were outlined in Milan by Professor Christian Becker, from the Nuffield Department of Women’s and Reproductive Health, University of Oxford. He provided a comprehensive overview of other key changes in best practice as recommended by the guideline, which was published in January, and the evidence underpinning these shifts in approach.
Until now, guidance on endometriosis diagnosis has been based on data from a systematic review from 2004, which has been used as a benchmark for recommending laparoscopy. However, Becker explained that more recent evidence, including a Cochrane review published in 2016, suggests that the sensitivity and specificity of imaging technology (MRI and transvaginal ultrasound) is equal to the former gold standard (laparoscopy).
The new guideline does not rule out laparoscopy but recommends that clinicians should only use it for patients with negative imaging results and/or where empirical treatment was unsuccessful or inappropriate. ‘We decided that if you find endometriosis then there’s no need for another laparoscopy,’ said Becker.
In addition to laparoscopy, his presentation covered peri-operative hormone treatment, pain, surgery, fertility and cancer.
Women with endometriosis not only endure severe pelvic pain but also pain as a result of surgical treatment. The guideline development group, which was chaired by Becker and ESHRE’s scientific director Nathalie Vermeulen, concluded that post-operative hormone treatment for women not wishing to get pregnant immediately may improve pain in the short-term (less than six months) and long-term for endometrioma and dysmenorrhea. This is a change from before, which did not recommended short-term hormone therapy.
The debate around whether to ablate or excise to reduce endometriosis-associated pain remains a hot debate because of a lack of robust data. Since publication of the 2013 guideline, more studies have emerged on ablation: one showed a small benefit and the other none. Therefore, the development group came up with a ‘cautious’ recommendation for clinicians to consider excision instead of ablation, said Becker.
Regarding fertility treatment, the previous guideline recommended extended administration of a GnRH agonist prior to ART to improve live birth rates in infertile women. However, this too was based on poor quality evidence from a Cochrane review, which has since been updated with data from two new studies. These suggest no benefit from an ultralong protocol.
The development group could not make a recommendation on which patients need treatment with ART after surgery. Their conclusion was that patients should be counselled with help of the Endometriosis Fertility Index surgery form, a tool able to predict the chance of pregnancy after surgery. If surgery is used, it should be to improve pain and not IVF outcomes, especially with any procedure on ovaries, said Becker.
Information around cancer is now more extensive, he said, than in the former guideline. The new advice is for clinicians to highlight to patients who ask that endometriosis is linked with a higher risk of ovarian, breast and thyroid cancers, but this increase is low when compared with the general population, and there is no association with a significantly higher risk of cancer overall. On this basis, systematic cancer screening is not necessary beyond existing population-based guidelines.
Endometriosis in adolescence is covered for the first time in the new guideline, and menopause more extensively. These were often neglected areas with the result that clinicians often regarded some patients as too young to have the condition or with a mistaken assumption that hormonal changes in menopause will ease endometriosis-symptoms in all women.
Concluding his talk, Becker emphasised the importance of this guideline for dissemination, which is also available in a version for patients. On this basis, he urged ESHRE members to get in touch if they wanted a version translated into their native language.
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