This case-based module will guide you through the latest evidence in the diagnosis and management of endometriosis.
Learning module objectives: Diagnosis and management of endometriosis
This module will update you on:
- How endometriosis is diagnosed
- When referral is appropriate
- Initial primary care management
- The use of HRT in women who have had a hysterectomy due to endometriosis
Endometriosis is a common gynaecological condition, characterised by the growth of endometrium-like tissue outside the uterus.1 It can be difficult to give an exact prevalence due to a number of factors, including that many women are treated empirically, to avoid the need for a laparoscopy which is the only way to confirm the diagnosis. Some women are asymptomatic, or may present with symptoms that don’t immediately lead to a diagnosis. Estimates range from 2–10% of the female population in general, rising to 50% of those who have subfertility. This implies that around 190 million women are affected worldwide.2 On average it takes 7.5 years from symptom onset until diagnosis.1
This module will use a case-based approach to explore some of the reasons for that and will discuss when it is appropriate to seek a formal diagnosis early, or when empirical management in primary care is sensible.
Case Study 1 – Miss P
Miss P is a 20-year-old woman who has come to see you about pelvic pain, which is causing her problems at college and in her part-time job. She tells you that she had her menarche at the age of 14 and her periods were fine for the first few years, but she remembers them becoming bad a year or so before her A-levels and they have continued to get more painful since then. She is concerned because the pain is now progressing to other parts of the month rather than just during her period.
What else would you ask Miss P?
Miss P has been logging her pain on an app and shows you that it has gradually progressed to the point where she only has a week or so per month that is completely pain free. She is concerned about her relationship with her boyfriend of two years because they are not having sex nearly so often as they used to, because she finds it so painful. He was her first sexual partner so she doesn’t know if pain during sex is normal. She has never tried to conceive and uses condoms for contraception. She is generally healthy, with nothing in the history to suggest that combined hormonal contraception would be contraindicated. On direct questioning she reflects that she does have some pain on opening her bowels which is worse during her periods, but she had never made the connection before. From the history so far, you think that endometriosis is probably top of your differential diagnosis.
What is the next step?
On examination you find general tenderness but nothing else. You explain to Miss. P that there are a variety of possible causes for her pain, endometriosis being one of them – she is relieved to be taken seriously, and had already done some research online which made her wonder if she might have endometriosis. You tell her she should have a transvaginal scan, for which the current wait in your area is around three months.
Which of the following courses of action are consistent with the NICE guidance on endometriosis?
Dr Toni Hazell is a GP in north London.
The full CPD module can be found on the Nursing in Practice 365 website.
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