NICE NG73: Endometriosis: Diagnosis and Management
Overview
NG73 covers the identification, investigation, and management of endometriosis in women and people presenting with suggestive symptoms, including organisation of care, referral pathways, and treatment options through medical and surgical management. It is the current NICE guideline on this topic; the older RCOG Green-top Guideline 24 (content/guidelines/rcog-gtg/gtg-24-endometriosis-investigation-and-management.md) held in this corpus is archived and should be treated as historical background only, not as the guideline of record.
Diagnosis
NICE recommends suspecting endometriosis (including in young people aged 17 and under) in anyone presenting with one or more of: chronic pelvic pain, period-related pain affecting daily activities, deep dyspareunia, period-related gastrointestinal symptoms, period-related urinary symptoms, or infertility associated with any of the above (1.3.1). Clinicians should offer an abdominal and pelvic (internal vaginal) examination to identify masses and pelvic signs (1.3.5).
Critically, laparoscopy is not required as a first-line investigation. NICE recommends offering a transvaginal ultrasound scan to all women or people with suspected endometriosis, even if pelvic/abdominal examination is normal (1.5.2), and states the possibility of endometriosis should not be excluded even if both examination and ultrasound are normal (1.5.4). A specialist transvaginal ultrasound or pelvic MRI should be considered to diagnose deep endometriosis and assess its extent (1.5.9). Laparoscopy is positioned as a further diagnostic step — to be considered even when ultrasound or MRI findings were normal (1.5.11) — rather than a mandatory gatekeeper to diagnosis or treatment. Additional investigations and referral should be carried out in parallel with, and alongside, initial pharmacological treatment rather than delaying it (1.5.1).
Referral
Referral to a general gynaecology service is indicated when initial treatment is ineffective, not tolerated, or contraindicated; when symptoms significantly affect daily activities; when symptoms are persistent or recurrent; or when pelvic signs are present without suspected deep disease (1.5.5). Referral to a specialist endometriosis service is indicated for suspected or confirmed endometrioma, deep endometriosis (including bowel, bladder, or ureteric involvement), or extrapelvic disease (1.5.6). Young people aged 17 and under with suspected or confirmed endometriosis should be referred to a paediatric and adolescent gynaecology service or specialist endometriosis service (1.5.7).
Management Ladder
Analgesia: a short trial (e.g. 3 months) of paracetamol and/or an NSAID is recommended for first-line pain management (1.4.2).
Hormonal treatment: offer hormonal treatment — for example the combined oral contraceptive pill or a progestogen — to those with suspected, confirmed, or recurrent endometriosis (1.4.6), with patients counselled that hormonal treatment reduces pain and has no permanent negative effect on subsequent fertility (1.4.5). GnRH antagonist options (e.g. linzagolix, relugolix combination therapy) are covered separately in NICE technology appraisals referenced from NG73.
Surgical management: surgery should be performed laparoscopically unless contraindicated, with results recorded via intra-operative imaging (1.9.3). At diagnostic laparoscopy, clinicians should consider laparoscopic treatment of peritoneal endometriosis not involving bowel/bladder/ureter and uncomplicated ovarian endometriomas (1.9.4). For deep endometriosis involving bowel, bladder, or ureter, 3 months of GnRH agonist pre-treatment may be considered as an adjunct to surgery (1.9.5). Excision is preferred over ablation for endometriomas, balanced against fertility wishes and ovarian reserve (1.9.6). Post-surgical hormonal treatment (e.g. COC) should be considered to prolong the benefits of surgery (1.9.7).
High-Yield Exam Points
- Laparoscopy is not mandatory first-line — ultrasound (and MRI for deep disease) come first, and normal imaging does not exclude endometriosis.
- Investigation/referral should proceed in parallel with initial pharmacological treatment, not delay it.
- First-line analgesia: paracetamol and/or NSAID, trialled ~3 months.
- First-line hormonal options: COC or a progestogen.
- Endometrioma/deep/extrapelvic disease → refer to a specialist endometriosis service.
- Excision is preferred over ablation for endometriomas, weighed against ovarian reserve.
- Post-operative hormonal treatment prolongs surgical benefit.
Source: National Institute for Health and Care Excellence (NICE) — current primary source, supersedes the archived RCOG GTG 24 (11 November 2024)
Read the original on nice.org.uk
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