How new endometriosis guidelines will improve diagnosis, treatment

  • Researchers in Europe have created new guidelines for diagnosing and treating endometriosis.
  • They have made significant updates to five key areas in managing the condition, including diagnosis, treatment, and recurrence.
  • The new guidelines could help patients and clinicians better understand and manage the condition.

Endometriosis is a condition in which tissue similar to the lining inside the uterus grows outside the uterus. It affects around 190 millionTrusted Source — or 10% — of women and girls of reproductive age worldwide.

Although some people with endometriosis are asymptomatic, common symptoms include:

  • painful cramping, similar to menstrual cramps
  • long-term lower back and pelvic pain
  • abnormal periods
  • bowel and urinary problems, including pain, diarrhea, constipation, and bloating
  • blood in the stool or urine
  • nausea and vomiting
  • fatigue
  • pain during intercourse
  • spotting or bleeding between periods
  • infertility

While this is a common condition, people often only receive a diagnosis for it 8-12 yearsTrusted Source after symptom onset. More specific guidelines could improve diagnosis and treatment for people with the condition.

In a recent report, the European Society of Human Reproduction and Embryology (ESHRE) developed new clinical practice guidelines for diagnosing and treating endometriosis.

“These guidelines offer better ways to manage and treat endometriosis for physicians and hope and comfort for millions of women who have felt frustrated and desperate by this debilitating disease,” Dr. Sherry Ross, OB/GYN and Women’s Health Expert at Providence Saint John’s Health Center in Santa Monica, CA, told Medical News Today.

Major changes


In the previous 2014 guidelines, laparoscopy — a surgical procedure involving small inclusions in the abdomen to insert a camera — was considered the gold standard diagnostic tool.

Due to recent advancements in imaging modalities, operative risk, limited access to highly-qualified surgeons, and financial implications, the ESHRE now only recommends laparoscopy if imaging results are negative and treatments unsuccessful or inappropriate.

Pain treatment

The present guidelines now recommend GnRH agonist or GnRH antagonist treatments — which prevent the ovaries from making sex hormones by desensitizing the pituitary gland — as a second-line treatment option.

They also say that NSAIDs may aid postoperative pain, the guidelines note that this may affect conception if taken continuouslyTrusted Source.

Infertility treatment

Extended use of GnRH agonists before assisted reproduction techniques (ARTs) — including in vitro fertilization — is no longer recommended to increase fertility due to unclear benefits.

Meanwhile, the Endometriosis Fertility Index (EFI) was added as a treatment step to help patients decide how to achieve pregnancy postsurgery.


The current guidelines recommend hormone treatments, including combined hormonal contraceptives for at least 18-24 months after surgery to prevent a recurrence.

They add that ART does not increase recurrence in women with deep endometriosisTrusted Source — a single nodule larger than 1 centimeter (cm) in diameter outside the uterus or close to the lower 20 cm of the bowel.

In conversation with MNT, Dr. Yen Hope Tran, OB/GYN at MemorialCare Orange Coast Medical Center in Fountain Valley, CA, noted that the guidelines also recommend surgeons “perform cystectomy instead of drainage and coagulation, as cystectomy reduces recurrence of endometrioma and endometriosis-associated pain.”


“Often, endometriosis manifests in adolescence, even early adolescence, but teens are unlikely to know that their pain and other symptoms are not the norm,” said Dr. Tran. “Period pain during this time is not normal.”

“Teens and their physicians often don’t address endometriosis — or endo symptoms — in the few meetings they are likely to have. I find it useful to ask about them having to miss classes/skip school because of their symptoms,” she added.

When diagnosing and treating adolescents, the guidelines recommend clinicians carefully investigate possible risk factors for endometriosis, including positive family history, obstructive genital malformations, early first menstruation, and a short menstrual cycle.

To treat endometriosis in adolescents, they recommend hormonal contraceptives or progesterone as first-line hormone therapy.

The American College of Obstetricians and Gynecologists recommends NSAIDs as the mainstay of pain relief for adolescents with endometriosis.

The World Health Organization (WHO)Trusted Source also recommends that if GnRH agonists are considered for adolescents and young women, the potential side effects and long-term health risks should first be discussed with a clinician in a secondary or tertiary setting.

“[The guidelines emphasize] preservation of fertility. Adolescents with endometriosis should be informed of the risk of becoming infertile so that they can make a more informed decision about early surgical intervention, preservation of oocytes, and other steps should they ever want to have children,” said Dr. Tran.

The ESHRE hopes that the new guidelines will assist both patients and healthcare professionals in better understanding and dealing with endometriosis.

When asked what the main points are for patients and clinicians to be aware of from these guidelines, Dr. Tran said:

“Endometriosis is a serious disease. It causes perhaps as much as 50% of all cases of infertility [and] each case is different. Any correlation between getting pregnant and experiencing relief of endometriosis symptoms are regarded as rare, and amount to wishful thinking.”

“Endometriosis recurs quite frequently, and no one treatment is appropriate for every patient or every case. Later in life, different treatments may be called for. You’re never out of the woods with endometriosis. Damage from endo continues to cause problems for women even after menopause,” she explained.

“Talk to your doctor, don’t put off treatment. Relief from symptoms is possible. Preservation of fertility needs to start immediately; endometriosis is serious and should be taken seriously,” she concluded.

Endometriosis: Why is there so little research?

Women’s reproductive health attracts far less research funding than almost all other medical research. As for endometriosis — a condition that affects around 10% of women of reproductive age — the lack of research is particularly striking. This debilitating condition can impact day-to-day life, education, work, and mental health, but its cause remains unclear, and there is no cure for it. Why is it so underresearched?

“That time of the month,” “shark week,” “crimson tide,” “got the painters in,” “on the blob,” “visit from Aunt Flo,” “the curse” — these are just a few of the many euphemisms for something experienced by 50% of the female adult population: menstruation. But why are there so many? Are we afraid to call it by its name?

Could it be that society’s reluctance to speak plainly about periods is one of the reasons why issues with women’s reproductive health are so underrecognized and underresearched?

Most females start to menstruate between the ages of 9 and 15. Monthly cycles continue until the menopause, which, on average, happens at around 52 years of age. So most women will have in the region of 450 periods during their life.

For around 20%Trusted Source of women, these are merely a monthly inconvenience. But for more than 80%, they are accompanied by some measure of pain. And for 1 in 4 womenTrusted Source, the pain can be severe enough to impact daily life.

We often normalize period pain as “part of being a woman.” For many, mild to moderate pain associated with menstruation can be controlled with over-the-counter pain relief, diet, and exercise.

However, debilitating pain is another matter. Menstrual Matters, a nonprofit online information hub, states that period pain “should not be regularly severe and debilitating.”

If it is, there is likely to be an underlying cause, which may need medical investigation. For pain that persists, occurs in the run-up to periods, and does not respond to pain relief, that cause may be endometriosis.

Endometriosis is “a systemic disease that is often painful and chronic.” Current estimates suggest it affects 176 million reproductive-age women worldwide.

Symptoms can include:

  • debilitating pain during menstruation
  • excessive bleeding during periods
  • pelvic pain at other times of the month
  • lower back pain
  • pain when emptying the bladder or bowels
  • pain during and after sexual intercourse

In severe cases, endometriosis can cause fertility issues. Some 40% of women with infertility also have endometriosis.

The condition is characterized by the growth of tissue similar to the endometrium, or womb lining, in areas outside the uterus. This tissue — endometrial lesionsTrusted Source — commonly grows in the following areas, though it can also infiltrate other parts of the body, such as the:

  • ovaries
  • fallopian tubes
  • ureters
  • bowels and bladder
  • abdominal wall

In line with the menstrual cycle, the lesions grow and bleed, forming scar tissue. This bleeding, inflammation, and scarring cause the characteristic pain of endometriosis.

A major issue with endometriosis is getting a diagnosis.

A 2019 review in the American Journal of Obstetrics and Gynecology (AJOG) explained why this might be:

“Despite its high prevalence and cost, endometriosis remains underfunded and underresearched, greatly limiting our understanding of the disease and slowing much-needed innovation in diagnostic and treatment options.”

Researchers acknowledge that endometriosis presents complex diagnostic challenges. Because the symptoms vary so much, the condition is often misdiagnosed as bowel and digestive disorders.

One 2020 United States studyTrusted Source recorded that 75.2% of patients reported being misdiagnosed with another physical health (95.1%), a mental health problem (49.5%), or both before they received an endometriosis diagnosis.

This study reported that misdiagnosis with a mental health problem was more common in those with younger age of endometriosis symptom onset.

The difficulty often leads to long delays between first reporting symptoms and a diagnosis of endometriosis. On average, women wait some 8.5 years for endometriosis to be confirmed, with some waiting much longer.

Doctors go through several stages to diagnose the condition, starting with palpating the abdomen to feel for lesions. They may use transvaginal ultrasound and MRI scans, but these do not always show lesions.

Healthcare professionals can only make a firm diagnosis of endometriosis by laparoscopy. This is a surgical process done under general anesthesia where a camera is inserted through a small incision in the abdomen to view the pelvic organs.

A 2021 focus group study in the Netherlands identified several issues with diagnosing endometriosis:

  • Most women do not feel their symptoms are taken seriously.
  • Many women believe their experiences of menstruation are normal, often because of what they are told by their mothers, so they do not seek treatment.
  • Medical professionals find it hard to differentiate between “normal” menstrual complaints and signs or symptoms suggestive of endometriosis.

Initially, most women are offered nonsteroidal anti-inflammatory drugsTrusted Source such as ibuprofen. However, little research has been done into whether these alleviate the severe pain caused by endometriosis, and anecdotal evidence suggests they have little effect.

As endometriosis is estrogen-dependent, medications that inhibit estrogen can be effective in controlling pain and inhibiting the growth of lesions. These include oral birth control pills and shots (Depo-Provera). However, some women experience side effectsTrusted Source from these, such as headaches, irregular bleeding, and weight gain.

Gonadotropin-releasing hormone treatments offer an alternative. By suppressing reproductive hormones, they also restrict the growth of lesions. The side effect of suppressing these hormones is menopausal symptoms, such as hot flashes, tiredness, sleep issues, vaginal dryness, and joint pain. However, people can take low dose hormone replacement therapy to alleviate these.

For severe pain, or when other treatments have proven ineffective, surgery will be considered. Laparoscopy, as well as being used for diagnosis, is also used to remove endometrial lesions.

Most people gain short-term pain relief after the removal of lesions, and for some, the effect is long lasting. However, according to the American College of Obstetricians and Gynaecologists, up to 80% of women see their pain return within 2 years.

As a last resort, hysterectomy — removal of the uterus — may be considered, but evidence for its benefits in treating endometriosis is inconclusiveTrusted Source. It is a major irreversible procedure, and a woman who has a hysterectomy will no longer have periods or become pregnant.

In the U.S., endometriosis is diagnosed in approximately 1 in 10 women of reproductive age — diabetes is diagnosed in around 10%Trusted Source of the U.S. population, both male and female.

In 2020, the U.S. government announced that funding for endometriosis research would be doubled to $26 million annually. In the same year, the National Institutes of Health (NIH) reported research spending on diabetes of $1,156 million.

Why the discrepancy? A 2021 studyTrusted Source into gender disparity in research funding found that the “NIH applies a disproportionate share of its resources to diseases that affect primarily men, at the expense of those that affect primarily women.”

The authors went further, stating that diseases affecting primarily or solely men tended to be overfunded, whereas those affecting mostly or only women were underfunded.

And the pattern is repeated in the United Kingdom, where a 2018 analysis by the U.K. Clinical Research Collaboration found that only 2.1% of publicly funded medical research went to reproductive health and childbirth.

According to Emma Cox, Chief Executive of Endometriosis UK, the National Institute for Health Research has funded more than 8,000 projects since its inception in 2006, only 11 of which address endometriosis.

“Women’s health, including endometriosis, has historically attracted far less research funding than other areas. We think this is because of a mixture of taboo and ignorance — whatever the reason, we are determined to put it right.”

– Emma Cox, Endometriosis UK

Lack of funding is not the only problem. Endometriosis is a complex condition. The symptoms vary so much between women that doctors used to think it was more than one condition. Therefore, it can be hard for researchers to know where to begin.

Some research has been done on animal models, but there are obstacles. Since primates are the most similar to people, they would be the best animals for modeling endometriosis. However, there are many objections to their use.

To avoid this problem, a team led by Prof. Philippa Saunders, chair of reproductive steroids at the University of Edinburgh, is developing a mouse model to study endometriosis. “The lowest species in which we can really do something meaningful is the mouse. That’s why the mouse is such an important model in reproductive research,” she says.

The researchers are studying the early development of the disease, with the aim of finding indicators of endometriosis in the blood. They hope this might provide a way of identifying the disease early before damage occurs.

However, Prof. Saunders is frustrated by the lack of funding for endometriosis research: “This progress was only possible because of increased pressure from patient groups who have been much more vocal over the last few years, working with clinical professionals to lobby funders.”

According to the 2019 review of endometriosis research in AJOG, “[c]omprehensive and interdisciplinary approaches to disease management and increased education and disease awareness for patients, healthcare providers, and the public are needed to remove stigma, increase timely and accurate diagnosis and treatment, and allow for new advancements.”

Emma Cox is one of many calling for more action:

“We would like government and other funders to address the historic underfunding of endometriosis research in order to identify the cause of the condition, work towards a cure, and develop better treatments. Developing better treatments is vital given that endometriosis can be a chronic and debilitating condition and current treatment options don’t work for everyone.”

As recently as 2020, the UK’s All-Party Parliamentary Group (APPG) on Endometriosis report highlighted that the cause of the condition was still unclear.

“Historically, with limited investment in research into women’s health in general, there’s been so little investment in research into endometriosis that we don’t even know what causes it, and without knowing the cause, a cure cannot be found,” it says.

The APPG called for “[c]ommitment for vital investment in research into the cause of endometriosis, treatment and management options, and diagnosis,” adding that:

“Without investment in research, this condition will rob the next generation of women [of] the education, care, and support they deserve.”

Lobbying groups and charities in both the U.K. and U.S. are working hard to raise awareness of endometriosis. But what is really needed is government commitments to fund more research.

Whether these will be forthcoming remains to be seen.

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