JOURNAL

Diagnosing
and assessing Pembimbing
endometriosis dr. Nicko Pisceski, Sp.OG(K)
dr. Dafnil Akhir Putra, Sp.OG

NICE Pathways
Abrar Risandi
Budi Haryadi
John Rico Manalu
M. Abi Syaifullah
M. Ilham Assalam
Widya Cahya
1
Woman with
suspected
endometriosis
No additional
information
 Symptoms and signs

2 Chronic pelvic pain

Period-related pain (dysmenorrhoea)

Deep pain during or after sexual intercourse

Cyclical GIT symptoms

 Symptoms and signs

2 Cycical urinary symptoms

Infertility in association with 1 or more of the

above
3 When to refer women with
suspected or confirmed endometriosis

Severe,
persistent, or Pelvic sign of
recurrent endometriosis
symptoms

Initial management is not effective, not tolerated or contraindicated

4
Serum
A raised serum
CA125 CA125  maybe
Present
having
DO NOT USE to endometriosis 35
despite a
normal
IU/ml or more
DIAGNOSE serum
< 35 IU/ml
Women with symptoms or
signs suggestive of endometriosis
 5
Abdominal & pelvic examination

Tender
Reduced
Enlargement nodularity
organ
mobility Visible vaginal endometriotic
lesions
 6 Ultrasound
To investigate
even pelvic examination is normal
TRANSVAGINAL
To identify endometriomas and deep
endometriosis involving
Bowell, bladder or ureter
If not appropriate, consider transabdominal
7
Pelvic MRI
To identify endometriomas
and deep endometriosis
DO NOT USE to involving Bowell, bladder
DIAGNOSE or ureter
 Diagnostic laparoscopy

8 Consider laparoscopy, even normal ultrasound

Suspected deep endometriosis involving bowel,

bladder, or ureter, consider a pelvic ultrasound
or MRI before laparoscopy

During laparoscopy, should perform a systematic

inspection of the pelvis
 8
Diagnostic laparoscopy
During laparoscopy, consider taking biopsy

To To exclude malignancy if an
confirmed endometrioma is treated but not
diagnosis excised
9 Staging
Should document a detailed information of the appearance and site
of endometriosis
10
Monitoring for Deep endometriosis
involving the bowel,
women with bladder, or ureter
confirmed
OR
endometriosis
Consider follow-up 1 or more endometrioma is
with or without > 3cm
examination and pelvic
11 Management
Managing endometriosis

NICE Pathways
1
Woman With
Suspected
or Confirmed
Endometriosis
No additional
information
2 Offer treatment according to symptoms,
preferences and priorities

Advise women that the available evidence does not support the use
of traditional Chinese medicine or other Chinese herbal medicines
or supplements for treating endometriosis.
3 For women with endometriosis-related
pain, discuss the benefits and risks of
Pharmacological analgesics
management Consider a short trial (for example, 3
months) of paracetamol or an
NSAID(alone or in combination) for first-
line management of endometriosis-
related pain.
Analgesics
3 Pharmacological management
If a trial of paracetamol or an NSAID (alone or in combination) does
not provide adequate pain relief, consider other forms of pain
management and referral for further assessment.
3 Pharmacological management
Neuromodulators and neuropathic pain treatments

NICE's recommendations on neuropathic pain

 3 Pharmacological management
Hormonal treatments
Explain to women with suspected or confirmed
endometriosis that early hormonal treatment for
endometriosis can reduce pain and has no permanent
negative effect on subsequent fertility
hormonal treatment (for example, the combined oral
contraceptive pill or a progestogen)
3 Pharmacological management
If initial hormonal treatment for endometriosis is not effective, not
tolerated or is contraindicated, refer the woman to a gynaecology
service
Referral after initial
hormonal treatment
4

Surgical
management
No additional
information
5 Discuss to patient about surgical
option
• what a laparoscopy involves
• that laparoscopy may include surgical treatment (with prior
patient consent)
• how laparoscopic surgery could affect endometriosis
symptoms
• the possible benefits and risks of laparoscopic surgery
• the possible need for further surgery (for example, for
recurrent endometriosis or if complications arise)
• the possible need for further planned surgery for deep
endometriosis involving the bowel, bladder or ureter
6 Perform surgery for endometriosis
laparoscopically unless there are
contraindications.
Surgical options During a laparoscopy to diagnose
endometriosis, consider laparoscopic
treatment of the following, if present:
peritoneal endometriosis not involving the
Laparoscopic bowel, bladder or ureter
uncomplicated ovarian endometriomas.
treatment
6
After laparoscopic excision or ablation of
Surgical options endometriosis, consider hormonal
treatment (with, for example, the
combined oral contraceptive pill)2, to
Combination prolong the benefits of surgery and
manage symptoms.
treatment
6
NICE has published interventional
Surgical options procedures guidance on laparoscopic
helium plasma coagulation for the
Laparoscopic treatment of endometriosis with special
arrangements for consent and for audit or
helium plasma research
coagulation
 6 If hysterectomy is indicated (for example,
if the woman has adenomyosis or heavy
menstrual bleeding that has not
Surgical options responded to other treatments), excise all
visible endometriotic lesions at the time
of the hysterectomy.
Hysterectomy in Perform hysterectomy (with or without
oophorectomy) laparoscopically when
combination with combined with surgical treatment of
surgical management endometriosis, unless there are
contraindications.
 For women thinking about having a hysterectomy,

6 discuss:
what a hysterectomy involves and when it may be
needed
Surgical options the possible benefits and risks of hysterectomy
the possible benefits and risks of having oophorectomy
at the same time
how a hysterectomy (with or without oophorectomy)
could affect endometriosis symptoms
Hysterectomy in that hysterectomy should be combined with excision of
combination with all visible endometriotic lesions
endometriosis recurrence and the possible need for
surgical management further surgery
the possible benefits and risks of hormone replacement
therapy after hysterectomy with oophorectomy (also
see NICE's recommendations on menopause).
 7 Surgical management if fertility is a priority

Excision or ablation of endometriosis +

adhesiolysis for endometriosis not
involving the bowel, bladder or ureter
Surgical
management Laparoscopic ovarian cystectomy with
excision of the cyst wall to women with
ovarian endometriomas
 7
Surgical management if fertility is a priority
Discuss the benefits and risks of
laparoscopic surgery as a
treatment option for women who
have deep endometriosis
involving the bowel, bladder or
ureter and who are trying to
conceive
Topics to discuss may include:
• whether laparoscopic surgery may alter
the chance of future pregnancy
• the possible impact on ovarian reserve
• the possible impact on fertility if
complications arise
• alternatives to surgery
• other fertility factors
7 Surgical management if fertility is a priority

Do not offer postoperative hormonal treatment to women with

endometriosis who are trying to conceive, because it does not
improve spontaneous pregnancy rates
Thank you