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Guideline Summary
Guideline Title
Management of endometriosis.
Bibliographic Source(s)
American College of Obstetricians and Gynecologists (ACOG). Management of endometriosis. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2010 Jul. 14 p. (ACOG practice bulletin; no. 114).  [129 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American College of Obstetricians and Gynecologists (ACOG). Medical management of endometriosis. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 1999 Dec. 14 p. (ACOG practice bulletin; no. 11). [99 references]

Scope

Disease/Condition(s)
  • Endometriosis, including extrapelvic endometriosis
  • Endometriosis-related pelvic pain
  • Endometriosis-induced infertility
Guideline Category
Assessment of Therapeutic Effectiveness
Diagnosis
Evaluation
Management
Treatment
Clinical Specialty
Obstetrics and Gynecology
Surgery
Intended Users
Physicians
Guideline Objective(s)
  • To aid practitioners in making decisions about appropriate obstetric and gynecologic care
  • To present the evidence, including risks and benefits, for the effectiveness of medical and surgical therapy for women who experience symptoms and problems believed to be secondary to endometriosis
Target Population

Women with endometriosis

Interventions and Practices Considered

Diagnosis

  1. History and physical examination
  2. Imaging studies (transvaginal ultrasonography, magnetic resonance imaging, and computed tomography)
  3. Histology of lesions removed at surgery
  4. Cystoscopy with biopsy in case of suspicion of bladder endometriosis
  5. Cancer antigen (CA) 125 marker
  6. Disease classification by the American Society for Reproductive Medicine (ASRM)

Management/Treatment

Medical Suppressive Therapy for Pain Symptoms

  1. Nonsteroidal anti-inflammatory drugs (NSAIDs)
  2. Oral norethindrone acetate
  3. Danazol
  4. Combined oral contraceptives (OCs)
  5. Depot medroxyprogesterone acetate (DMPA)
  6. Gonadotropin-releasing hormone (GnRH) agonists
  7. Intrauterine progestin use with the levonorgestrel intrauterine system
  8. "Add-back" regimens with GnRH agonists

Surgical Management

  1. Surgical excision of endometriosis
  2. Presacral neurectomy (considered but no recommendation made)
  3. Removal of endometriomas
  4. Hysterectomy with or without bilateral salpingo-oophorectomy
Major Outcomes Considered
  • Clinical utility of diagnostic tests
  • Rates of endometriosis recurrence
  • Incidence of pain
  • Safety and efficacy of treatment
  • Pregnancy rates

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' (ACOG's) own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985 and January 2010. The search was restricted to articles published in the English language. Priority was given to the articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document.

Guidelines published by organizations or institutions such as the National Institutes of Health and ACOG were reviewed, and additional studies were located by reviewing bibliographies of identified articles.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force.

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician-gynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Level C recommendations.

Rating Scheme for the Strength of the Recommendations

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Levels of Recommendations

Level A - Recommendations are based on good and consistent scientific evidence.

Level B - Recommendations are based on limited or inconsistent scientific evidence.

Level C - Recommendations are based primarily on consensus and expert opinion.

Cost Analysis

The guideline developers reviewed published cost analyses.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

Recommendations

Major Recommendations

The grades of evidence (I-III) and levels of recommendations (A-C) are defined at the end of "Major Recommendations" field.

The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):

  • Transvaginal ultrasonography is the imaging modality of choice when assessing the presence of endometriosis.
  • Medical suppressive therapy improves pain symptoms; however, recurrence rates are high after the medication is discontinued.
  • There is significant short-term improvement in pain after conservative surgical treatment; however, as with medical management, there is also a significant rate of pain recurrence.
  • Medical suppressive therapies such as oral contraceptives (OCs) or gonadotropin-releasing hormone (GnRH) agonists for endometriosis-associated infertility are ineffective.
  • Surgical management of endometriosis-related infertility does improve pregnancy rates, but the magnitude of improvement is unclear.
  • Excision of an endometrioma is superior to simple drainage and ablation of the cyst wall.
  • When relief of pain from treatment with a GnRH agonist supports continued therapy, the addition of add-back therapy reduces or eliminates GnRH agonist-induced bone mineral loss and provides symptomatic relief without reducing the efficacy of pain relief.

The following recommendations are based on limited or inconsistent scientific evidence (Level B):

  • After an appropriate pretreatment evaluation (to exclude other causes of chronic pelvic pain) and failure of initial treatment with OCs and non-steroidal anti-inflammatory drugs (NSAIDs), empiric therapy with a 3-month course of a GnRH agonist is appropriate.
  • In patients with known endometriosis and dysmenorrhea, OCs and oral norethindrone or depot medroxyprogesterone acetate (DMPA) are effective compared with placebo and are equivalent to other more costly regimens.
  • Long-term (at least 24 months) OC use is effective in reducing endometrioma recurrence as well as a reduction in the frequency and severity of dysmenorrhea.
  • Hormone therapy with estrogen is not contraindicated after hysterectomy and bilateral salpingo-oophorectomy for endometriosis.
  • In patients with normal ovaries, a hysterectomy with ovarian conservation and removal of the endometriotic lesions should be considered.

The following recommendation is based primarily on consensus and expert opinion (Level C):

  • When medical management has failed, undergoing definitive surgical management is appropriate in those who do not desire future fertility.

Definitions:

Grades of Evidence

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments could also be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Levels of Recommendations

Level A - Recommendations are based on good and consistent scientific evidence.

Level B - Recommendations are based on limited or inconsistent scientific evidence.

Level C - Recommendations are based primarily on consensus and expert opinion.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Improved medical and surgical therapy of symptoms and problems believed to be secondary to endometriosis

Potential Harms
  • Gonadotropin-releasing hormone agonists may have significant side effects, including hot flushes, vaginal dryness, and osteopenia.
  • It is important in all surgery for removal of endometriomas that the patient be informed that the surgery may damage the ovary and reduce ovarian reserve.
  • Depot medroxyprogesterone acetate (DMPA) can cause bone loss.
  • There are limited data to indicate that hormone therapy may stimulate the growth of residual ovarian or endometrial tissue after total hysterectomy and bilateral salpingo-oophorectomy if all visible disease was removed. There is also a concern about the possibility of estrogen-induced malignant transformation in residual endometriosis implants. This has led some health care providers to recommend the routine addition of a progestin to the estrogen therapy. However, there is no outcomes-based evidence to support this recommendation.
  • Danazol has a side effect profile, which includes acne, hirsutism, and myalgias, that is more severe than other drugs available.
  • The levonorgestrel intrauterine system was shown to cause unacceptable irregular bleeding, persistent pain, or weight gain in approximately 40% of users in one reported trial.

Qualifying Statements

Qualifying Statements

The information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care. These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Audit Criteria/Indicators
Foreign Language Translations
Patient Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
American College of Obstetricians and Gynecologists (ACOG). Management of endometriosis. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2010 Jul. 14 p. (ACOG practice bulletin; no. 114).  [129 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
1999 Dec (revised 2010 Jul)
Guideline Developer(s)
American College of Obstetricians and Gynecologists - Medical Specialty Society
Source(s) of Funding

American College of Obstetricians and Gynecologists (ACOG)

Guideline Committee

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Gynecology

Composition of Group That Authored the Guideline

Not stated

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American College of Obstetricians and Gynecologists (ACOG). Medical management of endometriosis. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 1999 Dec. 14 p. (ACOG practice bulletin; no. 11). [99 references]

Guideline Availability

Electronic copies: Not available at this time.

Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 933104, Atlanta, GA 31193-3104; telephone, 800-762-2264; e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site External Web Site Policy.

Availability of Companion Documents

A proposed performance measure is included in the original guideline document.

Patient Resources

The following is available:

  • Endometriosis. Atlanta (GA): American College of Obstetricians and Gynecologists (ACOG); 2008. Available from the ACOG Web site External Web Site Policy. Copies are also available in Spanish External Web Site Policy.

Print copies: Available for purchase from the ACOG Distribution Center, PO Box 933104, Atlanta, GA 31193-3104; telephone, 800-762-2264; e-mail: e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI on January 14, 2005. This summary was updated by ECRI Institute on September 16, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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