Diagnosis and Treatment of Endometriosis. Guideline of the DGGG, SGGG and OEGGG (S2k Level, AWMF Registry Number 015/045, August 2020)

Abstract

Aims The aim of this official guideline published and coordinated by the German Society of Gynaecology and Obstetrics (DGGG) in cooperation with the Austrian Society for Gynaecology and Obstetrics (OEGGG) and the Swiss Society for Gynaecology and Obstetrics (SGGG) was to provide consensus-based recommendations for the diagnosis and treatment of endometriosis based on an evaluation of the relevant literature.

Methods This S2k guideline represents the structured consensus of a representative panel of experts with different professional backgrounds commissioned by the Guideline Committee of the DGGG, OEGGG and SGGG.

Recommendations Recommendations on the epidemiology, aetiology, classification, symptomatology, diagnosis and treatment of endometriosis are given and special situations are discussed.

Key words

endometriosis - diagnosis - treatment - pelvic pain - guideline

I  Guideline Information

Guideline programme of the DGGG, OEGGG and SGGG

For information about the guideline programme, please refer to the end of the guideline.

Citation format

Diagnosis and Treatment of Endometriosis. Guideline of the DGGG, SGGG and OEGGG (S2k Level, AWMF Registry Number 015/045, August 2020). Geburtsh Frauenheilk 2021; 81: 422 – 446

Guideline documents

The complete long version together with a slide version of these guidelines and a list of the conflicts of interest of all authors involved are available on the homepage of the AWMF: http://www.awmf.org/guidelinen/detail/ll/015-045.html

Guideline group

See [Tables 1] and [2].

Tab. 1 Lead author and/or coordinating lead author of the guideline.

Author	AWMF professional society
PD Dr. Stefanie Burghaus	German Society of Gynaecology and Obstetrics [Deutsche Gesellschaft für Gynäkologie und Geburtshilfe e. V.] (DGGG)
Dr. Sebastian D. Schäfer	German Society of Gynaecological Endocrinology and Reproductive Medicine [Deutsche Gesellschaft für Gynäkologische Endokrinologie und Fortpflanzungsmedizin e. V.] (DGGEF)
Prof. Dr. Uwe Andreas Ulrich	Society of Gynaecological Endoscopy [Arbeitsgemeinschaft für Gynäkologische Endoskopie] (AGE)

Tab. 2 Contributing guideline authors.

DGGG working group (AG)/AWMF/non-AWMF professional society/organisation/association	Mandate holder/author	Deputy/author
Professional Association of Gynaecologists	PD Dr. med. Stefanie Burghaus	Prof. Dr. med. Dr. phil. Dr. h. c. mult. Andreas D. Ebert
German Society for General and Visceral Surgery (DGAV)	Dr. med. Sebastian D. Schäfer
German Society of Gynaecology and Obstetrics (DGGG)	Prof. Dr. med. Uwe Andreas Ulrich
German Society of Gynaecological Endocrinology and Reproductive Medicine (DGGEF)	Dr. med. Volker Heinecke
Society of Gynaecological Endoscopy (AGE)	Prof. Dr. med. Jan Langrehr
Society of Paediatric and Adolescent Gynaecology	Prof. Dr. med. Matthias W. Beckmann	Dr. med. Christine Fahlbusch
Society of Gynaecological Oncology (AGO)	Prof. Dr. med. Tanja Fehm	PD Dr. med. Thomas Papathemelis
IMed Committee	Prof. Dr. med. Andreas Müller	PD Dr. med. Carolin C. Hack
German Society of Psychosomatic Gynaecology and Obstetrics (DGPFG e. V.)	PD Dr. med. Friederike Siedentopf
Society of University Reproductive Medicine Centres (URZ)	PD Dr. med. Andreas Schüring	Prof. Dr. med. Katharina Hancke
Medical Society for Health Promotion (ÄGGF)	Dr. med. Christine Klapp	Dr. med. Heike Kramer
German Pathology Society	Prof. Dr. med. Dietmar Schmidt	Prof. Dr. med. Lars-Christian Horn
German Society of Psychosomatic Medicine and Medical Psychotherapy (DGPM)	Prof. Dr. med. Kerstin Weidner	PD Dr. med. Christian Brünahl
German Society for Rehabilitation Sciences	Dr. Iris Brandes, MPH
German Reproductive Medicine Society (DGRM)	Prof. Dr. med. Katharina Hancke
German College of Psychosomatic Medicine (DKPM)	PD Dr. med. Christian Brünahl	Prof. Dr. med. Kerstin Weidner
German Radiology Society	Dr. med. Christian Houbois
German Pain Society	Prof. Dr. med. Winfried Häuser
German Society of Thoracic Surgery (DGT)	Dr. med. Wojciech Dudek	Prof. Dr. med. Dr. h. c. Horia Sirbu
German Society of Urology	Dr. med. Isabella Zraik
Austrian Society of Gynaecology and Obstetrics (OEGGG)	Assoc. Prof. Priv.-Doz. Dr. Beata Seeber	Prof. Dr. med. Peter Oppelt
Swiss Society of Gynaecology and Obstetrics (SGGG)	Prof. Dr. med. Michael Müller	Dr. med. Peter Martin Fehr
Czech Society of Gynaecology and Obstetrics	Prim. Dr. med. Radek Chvatal	Dr. med. Jan Drahoňovský
Endometriosis research foundation (SEF)	Prof. Dr. Dr. h. c. Karl-Werner Schweppe	Prof. Dr. med. Sylvia Mechsner
European endometriosis league (EEL)	Prof. Dr. med. Stefan. P. Renner	Dr. med. Harald Krentel
Endometriosis association Germany	Daniela Soeffge	Dr. Heike Matuschewski
Endometriosis association Austria	Ines Mayer	Armelle Müller

Dr. Monika Nothacker, MPH (AWMF Institute for Medical Knowledge Management), who took over moderation of the guideline, is gratefully acknowledged.

Gender note

For better readability, simultaneous use of all language forms is omitted throughout. All female or male references to persons apply to each sex.

Abbreviations employed

ASRM: American Society for Reproductive Medicine

COC: combined oral contraceptive

DIE: deep infiltrating endometriosis

DRG: diagnosis related groups

EAOC: endometriosis-associated ovarian cancer

GnRH: gonadotropin-releasing hormone

HIFU: high frequency ultrasound

MRI: magnetic resonance imaging

NSAID: nonsteroidal anti-inflammatory drug

PMWA: percutaneous microwave ablation

UAE: uterine artery embolisation
 

II  Guideline Application

Purpose and objectives

The purpose of this guideline is to provide information and advice about the diagnosis, treatment and further care of endometriosis as well as specific situations for women with already confirmed or suspected endometriosis and for physicians who treat women with endometriosis.

In addition, the information is intended to form the basis for joint decision-making in certified endometriosis clinics, units or centres. The defined statements and recommendations will also be used to develop quality indicators.

Area of patient care

Inpatient, outpatient and day-care sector.

Target user group/target audience

This guideline is aimed at the following groups: office-based gynaecologists, gynaecologists in hospitals, reproductive medicine physicians, pathologists, urologists, visceral surgeons, radiologists, psychosomatic specialists and psychologists, pain therapists, patients with or suspected to have endometriosis, specialists in rehabilitation medicine, general physicians, paediatricians and womenʼs interest groups that represent womenʼs interests (patient and self-help organisations).

Additional targeted groups (for information purposes): nursing staff, members of occupational groups involved in the care of patients with confirmed or suspected endometriosis (e.g., stoma therapists), funding bodies and German national and regional health policy institutions and decision-makers.

Adoption and period of validity

The validity of this guideline was confirmed by the executive boards/heads of the participating professional societies/working groups/organisations/associations, as well as by the boards of the DGGG and the DGGG Guidelines Commission and of the SGGG and OEGGG in July 2020 and was thus approved in its entirety. This guideline is valid from 01.08.2020 to 31.07.2023. Because of the contents of this guideline, this period of validity is only an estimate.

III  Methodology

Basic principles

The method used to prepare this guideline was determined by the class to which this guideline was assigned. The AWMF Guidance Manual (version 1.0) has set out the respective rules and requirements for different classes of guidelines. Guidelines are differentiated into the lowest (S1), intermediate (S2) and highest (S3) class. The lowest class is defined as a set of recommendations for action compiled by a non-representative group of experts. In 2004, the S2 class was divided into two subclasses: a systematic evidence-based subclass (S2e) and a structural consensus-based subclass (S2k). The highest S3 class combines both approaches.

This guideline was classified as: S2k.

Grading of recommendations

Grading of evidence based on the systematic search, selection, evaluation and synthesis of the evidence base followed by a grading of the evidence is not envisaged for S2k-level guidelines. The individual statements and recommendations are only differentiated by syntax, not by symbols ([Table 3]):

Tab. 3 Grading of recommendations (based on Lomotan et al. Qual Saf Health Care 2010).

Description of binding character	Expression
Strong recommendation, highly binding	must/must not
Recommendation, moderately binding	should/should not
Open recommendation, not binding	may/may not

Statements

Expositions of explanations of specific facts, circumstances or problems without any direct recommendations for action included in this guideline are referred to as “Statements”. It is not possible to provide any information about the grading of evidence for these statements.

Achieving consensus and strength of consensus

At structured NIH-type consensus-based conferences (S2k/S3 level), authorised participants attending the session vote on draft statements and recommendations. The process is as follows. A recommendation is presented, its contents are discussed, proposed changes are put forward, and finally, all proposed changes are voted on. If a consensus has not been achieved (≤ 75% of votes), there is another round of discussions, followed by a repeat vote. Finally, the extent of consensus is determined based on the number of participants ([Table 4]).

Tab. 4 Classification showing the extent of agreement for consensus-based decisions.

Symbol	Strength of agreement	Extent of agreement in percent
+++	Strong consensus	> 95% of participants agree
++	Consensus	> 75 – 95% of participants agree
+	Majority agreement	> 50 – 75% of participants agree
–	No consensus	< 51% of participants agree

Expert consensus

As the name already implies, this refers to consensus decisions taken with regard to Recommendations/Statements without a prior systematic search of the literature (S2k) or for which evidence is lacking (S2e/S3). The term “expert consensus” (EC) used here is synonymous with terms used in other guidelines such as “good clinical practice” (GCP) or “clinical consensus point” (CCP). The strength of the recommendation is graded as previously described in the section “Grading of recommendations”, i.e., purely semantically (“must”/“must not” or “should”/“should not” or “may”/“may not”) and without the use of symbols.

IV  Guideline

1  Epidemiology, aetiology, morbidity and manifestation of endometriosis

Figures on the prevalence and incidence vary according to the clinical situation and are also influenced by selective consideration.

Different concepts were developed to describe the possible causes for the development and persistence of the disease (e.g., implantation theory [1], coelom metaplasia theory [2], archimetra or “tissue injury and repair concept” [3], [4], but without finding a satisfactory final explanation. Rather, from combining the various concepts, it is assumed that genetic defects and epigenetic phenomena as well as other influences provide the conditions for specific changes to take place during implantation and metaplasia that will allow foci of endometriosis to develop in a milieu that is foreign for these cells. Important factors influencing this process include hyperperistalsis, arising from adaptations due to evolutional biology [4], hyperoestrogenisation, hyperperistalsis, inflammatory and immune processes, prostaglandin metabolism, angiogenesis, oxidative stress and various others [5], [6], [7].

The following are affected in decreasing frequency: pelvic peritoneum, ovaries, sacrouterine ligaments, rectovaginal septum/vaginal fornix, extragenital manifestations (e.g., rectosigmoid and bladder).

2  Basic principles of endometriosis classification (clinical/intraoperative, histological, DRG system)

2.1  Clinical/intraoperative classification of endometriosis

A clinical/intraoperative distinction depending on the location and extent is made between the following endometriosis entities: peritoneal endometriosis, ovarian endometriosis, deep infiltrating endometriosis (DIE) and uterine adenomyosis.

2.2  Histological classification of endometriosis

2.3  DRG system of endometriosis (ICD-10-GM-2019, OPS-2019)

Endometriosis is classified in the DRG system according to ICD-10-GM-2019 and this forms the basis of the consideration of endometriosis sites in section 6 ff below.

3  Symptoms and basic principles of diagnosis of endometriosis (investigation algorithm)

4  Basic principles of treatment of endometriosis

4.1  Hormonal treatment of endometriosis

The principle of effective hormonal treatment consists of induction of therapeutic amenorrhoea. In German-speaking countries, only the progestin dienogest and the gonadotropin-releasing hormone (GnRH) analogue leuprorelin acetate have been approved to date for the hormonal treatment of endometriosis.

Primary hormonal therapy

There have been increasing attempts to use progestins and oral contraceptives as first-line treatment prior to surgical diagnosis or treatment. There was no significant difference between primary pharmacological and operative therapy in pain relief [17]. However, valid data are lacking that would allow assessment in the long term of symptom relief, the probability of recurrence and the influence on fertility with primary hormonal therapy.

Postoperative hormonal therapy

The rate of endometrioma recurrence and the rate of symptoms such as dysmenorrhoea and chronic pain can be reduced by postoperative therapy with combined oral contraceptives in a long-term cycle [18]. This was also shown for dienogest [19]. Use of GnRH analogues for 6 instead of 3 months significantly reduced the risk of recurrence [20].

4.2  Pharmacological, non-hormonal therapy of endometriosis

Analgesics

Analgesics are used for the symptomatic treatment of patients with pain. In a Cochrane review from 2017 the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with endometriosis was analysed. Only two randomised controlled studies were identified, so that a conclusion regarding the effectiveness of NSAIDs and also subgroup analyses are not possible. The data regarding NSAIDs for (primary) dysmenorrhoea are much better and NSAIDs appear to be effective for the relief of menstrual pain [21].

4.3  Surgical treatment of endometriosis

5  Care structures for patients with suspected or confirmed endometriosis

Abb. 1 Agreed care algorithm of the guideline group (based on expert consensus, strength of consensus ++).

6  Diagnosis and treatment of endometriosis according to site

6.1  Endometriosis of the uterus (N80.0)

6.2  Endometriosis of the ovary and tube (N80.1 and N80.2)

The potential negative influence of the endometrioma on ovarian reserve and function is probably caused by stretching of the ovarian cortex, local inflammatory processes, oxidative stress and fibrosis of the ovary [22].

If assisted reproduction is planned, the prospect of success is probably not increased by prior endometrioma removal [22], [23].

6.3  Endometriosis of the pelvic peritoneum/peritoneal endometriosis (N80.3)

6.4  Endometriosis of the rectovaginal septum and vagina (N80.4)

6.5  Endometriosis of the bowel (N80.5)

6.6  Endometriosis in a skin scar (N80.6)

6.7  Endometriosis in the bladder and of the ureter (N80.8)

Even though isolated cases of endometriosis of the bladder treated pharmacologically are described in the literature [25], the treatment of endometriosis of the bladder in most cases consists of partial cystectomy [26], [27]. If the endometriosis nodule is located in proximity to the ureter ostia, a double J catheter is inserted immediately before the intervention.

In the case of endometriosis of the ureter, the first step is to attempt ureter decompression without segment resection or ureter implantation; ureteroneocystostomy should be performed only if this fails and the ureter and renal pelvis do not recover.

6.8  Rare extragenital endometriosis locations, extra-abdominal endometriosis (N80.8)

7  Special endometriosis situations

7.1  Endometriosis in adolescents

7.2  Endometriosis and desire for children

7.3  Endometriosis: pregnancy and delivery

With regard to pregnancy, there is now a fairly large number of studies that present the increased risks as follows:

• Miscarriage rate [28]

• Pre-term birth [29]

• Premature rupture of the membranes [30]

• Premature placental abruption [31]

• Placenta previa [31]

• Preeclampsia risk – varying opinions [32]

• SHIP – sudden haemoperitoneum in pregnancy (very rare) [33]

• Gestational diabetes [34]

7.4  Endometriosis and pain

7.5  Endometriosis and cancer

A patient with endometriosis has a very low risk overall of developing ovarian cancer because of the only slightly increased ovarian cancer risk as the lifetime risk of this is low anyway at 1.3%. In most of the published studies on endometriosis-associated ovarian cancer (EAOC), the risk of the disease in endometriosis patients is classified as moderate (RR, SIR or OR: 1.3 – 1.9) [37], [38], [39]. Unilateral salpingo-oophorectomy can be discussed, however, e.g., in perimenopausal women with endometriomas > 6 – 9 cm, since the risk of ovarian cancer in these patients is increased up to 13.2 times. Removal of the endometrioma alone does not reduce the risk in this group of patients [40].

7.6  Endometriosis and psychosomatic aspects

7.7  Endometriosis and association with other diseases

8  Rehabilitation, follow-up care and self-help

9  Integrative therapy in patients with endometriosis

There are a few small prospective randomised studies that investigated the different integrative therapy methods with regard to the effectiveness of pain reduction in primary dysmenorrhoea, though evidence of existing endometriosis very rarely had to be provided in these studies. The pain reduction was mainly in the placebo, comparator or control group and the active treatment group was rarely superior. The number of included patients/participants was usually rather low. The maximum study period or follow-up period was 6 to 12 months. The data are insufficient with regard to fertility.

Various Chinese herbal medicines, calcium, phototherapy, acupuncture, electroacupuncture, moxibustion, injection of local anaesthetics into pain trigger points, manual therapy and physical exercise can be used for the primary treatment of primary dysmenorrhoea.

Conflict of Interest/Interessenkonflikt

The conflicts of interests of the authors are listed in the long version of the guideline./Die Interessenkonflikte der Autoren sind in der Langfassung der Leitlinie aufgelistet.

• References/Literatur

• 1 Sampson JA. Metastatic or Embolic Endometriosis, due to the Menstrual Dissemination of Endometrial Tissue into the Venous Circulation. Am J Pathol 1927; 3: 93-110.43
• 2 Meyer R. Über den Stand der Frage der Adenomyositis, Adenomyome im allgemeinen und insbesondere über Adenomyositis seroepithelialis und Adenomyometritis sarcomatosa. Zentralbl Gynäkol 1919; 36: 745-750
• 3 Leyendecker G, Kunz G, Noe M. et al. Endometriosis: a dysfunction and disease of the archimetra. Hum Reprod Update 1998; 4: 752-762
• 4 Leyendecker G, Wildt L, Mall G. The pathophysiology of endometriosis and adenomyosis: tissue injury and repair. Arch Gynecol Obstet 2009; 280: 529-538
• 5 Gordts S, Koninckx P, Brosens I. Pathogenesis of deep endometriosis. Fertil Steril 2017; 108: 872-885.e1
• 6 Koninckx PR, Ussia A, Adamyan L. et al. Pathogenesis of endometriosis: the genetic/epigenetic theory. Fertil Steril 2019; 111: 327-340
• 7 Parazzini F, Esposito G, Tozzi L. et al. Epidemiology of endometriosis and its comorbidities. Eur J Obstet Gynecol Reprod Biol 2017; 209: 3-7
• 8 Hirsch M, Begum MR, Paniz E. et al. Diagnosis and management of endometriosis: a systematic review of international and national guidelines. BJOG 2018; 125: 556-564
• 9 Clement PB, Young RH. Atlas of Gynecologic Surgical Pathology. 4th ed. Edinburgh, London, New York, Oxford, Philadelphia, St. Louis, Sydney: Elsevier; 2020: 183-184
• 10 Cockerham AZ. Adenomyosis: a challenge in clinical gynecology. J Midwifery Womens Health 2012; 57: 212-220
• 11 McCluggage WG, Robboy SJ. Mesenchymal uterine tumors, other than pure smooth muscle neoplasms, and adenomyosis. In: Robboyʼs Pathology of the Female Reproductive Tract. 2nd ed.. Churchill Livingstone; 2008: 450-456
• 12 Burghaus S, Fehm T, Fasching PA. et al. The International Endometriosis Evaluation Program (IEEP Study) – A Systematic Study for Physicians, Researchers and Patients. Geburtshilfe Frauenheilkd 2016; 76: 875-881
• 13 Palla VV, Karaolanis G, Katafigiotis I. et al. Ureteral endometriosis: A systematic literature review. Indian J Urol 2017; 33: 276-282
• 14 Schliep KC, Chen Z, Stanford JB. et al. Endometriosis diagnosis and staging by operating surgeon and expert review using multiple diagnostic tools: an inter-rater agreement study. BJOG 2017; 124: 220-229
• 15 Wu D, Hu M, Hong L. et al. Clinical efficacy of add-back therapy in treatment of endometriosis: a meta-analysis. Arch Gynecol Obstet 2014; 290: 513-523
• 16 Tsai HW, Wang PH, Huang BS. et al. Low-dose add-back therapy during postoperative GnRH agonist treatment. Taiwan J Obstet Gynecol 2016; 55: 55-59
• 17 Chaichian S, Kabir A, Mehdizadehkashi A. et al. Comparing the Efficacy of Surgery and Medical Therapy for Pain Management in Endometriosis: A Systematic Review and Meta-analysis. Pain Physician 2017; 20: 185-195
• 18 Zorbas KA, Economopoulos KP, Vlahos NF. Continuous versus cyclic oral contraceptives for the treatment of endometriosis: a systematic review. Arch Gynecol Obstet 2015; 292: 37-43
• 19 Adachi K, Takahashi K, Nakamura K. et al. Postoperative administration of dienogest for suppressing recurrence of disease and relieving pain in subjects with ovarian endometriomas. Gynecol Endocrinol 2016; 32: 646-649
• 20 Zheng Q, Mao H, Xu Y. et al. Can postoperative GnRH agonist treatment prevent endometriosis recurrence? A meta-analysis. Arch Gynecol Obstet 2016; 294: 201-207
• 21 Marjoribanks J, Ayeleke RO, Farquhar C. et al. Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. Cochrane Database Syst Rev 2015; (07) CD001751 DOI: 10.1002/14651858.CD001751.pub3.
• 22 Keyhan S, Hughes C, Price T. et al. An Update on Surgical versus Expectant Management of Ovarian Endometriomas in Infertile Women. Biomed Res Int 2015; 2015: 204792
• 23 Tao X, Chen L, Ge S. et al. Weigh the pros and cons to ovarian reserve before stripping ovarian endometriomas prior to IVF/ICSI: A meta-analysis. PLoS One 2017; 12: e0177426
• 24 Riley KA, Benton AS, Deimling TA. et al. Surgical Excision Versus Ablation for Superficial Endometriosis-Associated Pain: A Randomized Controlled Trial. J Minim Invasive Gynecol 2019; 26: 71-77
• 25 Angioni S, Nappi L, Pontis A. et al. Dienogest. A possible conservative approach in bladder endometriosis. Results of a pilot study. Gynecol Endocrinol 2015; 31: 406-408
• 26 Ceccaroni M, Clarizia R, Ceccarello M. et al. Total laparoscopic bladder resection in the management of deep endometriosis: “take it or leave it.” Radicality versus persistence. Int Urogynecol J 2019; DOI: 10.1007/s00192-019-04107-4.
• 27 Knabben L, Imboden S, Fellmann B. et al. Urinary tract endometriosis in patients with deep infiltrating endometriosis: prevalence, symptoms, management, and proposal for a new clinical classification. Fertil Steril 2015; 103: 147-152
• 28 Hjordt Hansen MV, Dalsgaard T, Hartwell D. et al. Reproductive prognosis in endometriosis. A national cohort study. Acta Obstet Gynecol Scand 2014; 93: 483-489
• 29 Kim SG, Seo HG, Kim YS. Primiparous singleton women with endometriosis have an increased risk of preterm birth: Meta-analyses. Obstet Gynecol Sci 2017; 60: 283-288
• 30 Conti N, Cevenini G, Vannuccini S. et al. Women with endometriosis at first pregnancy have an increased risk of adverse obstetric outcome. J Matern Fetal Neonatal Med 2015; 28: 1795-1798
• 31 Berlac JF, Hartwell D, Skovlund CW. et al. Endometriosis increases the risk of obstetrical and neonatal complications. Acta Obstet Gynecol Scand 2017; 96: 751-760
• 32 Zullo F, Spagnolo E, Saccone G. et al. Endometriosis and obstetrics complications: a systematic review and meta-analysis. Fertil Steril 2017; 108: 667-672.e5
• 33 Vigano P, Corti L, Berlanda N. Beyond infertility: obstetrical and postpartum complications associated with endometriosis and adenomyosis. Fertil Steril 2015; 104: 802-812
• 34 Lalani S, Choudhry AJ, Firth B. et al. Endometriosis and adverse maternal, fetal and neonatal outcomes, a systematic review and meta-analysis. Hum Reprod 2018; 33: 1854-1865
• 35 Weidner K, Neumann A, Siedentopf F. et al. Chronischer Unterbauchschmerz: Die Bedeutung der Schmerzanamnese. Frauenarzt 2015; 56: 982-987
• 36 Hauser W, Bock F, Engeser P. et al. [Recommendations of the updated LONTS guidelines. Long-term opioid therapy for chronic noncancer pain]. Schmerz 2015; 29: 109-130
• 37 Somigliana E, Vigano P, Parazzini F. et al. Association between endometriosis and cancer: a comprehensive review and a critical analysis of clinical and epidemiological evidence. Gynecol Oncol 2006; 101: 331-341
• 38 Kim HS, Kim TH, Chung HH. et al. Risk and prognosis of ovarian cancer in women with endometriosis: a meta-analysis. Br J Cancer 2014; 110: 1878-1890
• 39 Zafrakas M, Grimbizis G, Timologou A. et al. Endometriosis and ovarian cancer risk: a systematic review of epidemiological studies. Front Surg 2014; 1: 14
• 40 Thomsen LH, Schnack TH, Buchardi K. et al. Risk factors of epithelial ovarian carcinomas among women with endometriosis: a systematic review. Acta Obstet Gynecol Scand 2017; 96: 761-778
• 41 Chen LC, Hsu JW, Huang KL. et al. Risk of developing major depression and anxiety disorders among women with endometriosis: A longitudinal follow-up study. J Affect Disord 2016; 190: 282-285
• 42 Evans S, Fernandez S, Olive L. et al. Psychological and mind-body interventions for endometriosis: A systematic review. J Psychosom Res 2019; 124: 109756
• 43 Lagana AS, La Rosa VL, Rapisarda AMC. et al. Anxiety and depression in patients with endometriosis: impact and management challenges. Int J Womens Health 2017; 9: 323-330
• 44 Coloma JL, Martinez-Zamora MA, Collado A. et al. Prevalence of fibromyalgia among women with deep infiltrating endometriosis. Int J Gynaecol Obstet 2019; 146: 157-163
• 45 Veasley: Chronic overlapping Pain Conditions. In: Häuser W, Perrot S. eds. Fibromyalgia Syndrome and Widespread Pain: From Construction to Relevant Recognition. Alphen aan den Rijn: Wolters Kluwer; 2018: 87-111
• 46 Wu CC, Chung SD, Lin HC. Endometriosis increased the risk of bladder pain syndrome/interstitial cystitis: a population-based study. Neurourol Urodyn 2018; 37: 1413-1418
• 47 Schweppe KW, Ebert AD, Kiesel L. Endometriosezentren und Qualitätsmanagement. Gynäkologe 2010; 43: 233-240 doi:10.1007/s00129-009-2484-x
• 48 Rahmenkonzept zur Nachsorge für medizinische Rehabilitation nach § 15 SGB VI der Deutschen Rentenversicherung. Stand: Juni 2015 (in der Fassung vom 1. Juli 2019). Accessed October 31, 2019 at: https://www.deutsche-rentenversicherung.de/SharedDocs/Downloads/DE/Experten/infos_reha_einrichtungen/konzepte_systemfragen/konzepte/rahmenkonzept_reha_nachsorge.pdf?__blob=publicationFile&v=4
• 49 Kofahl C. [Collective patient centeredness and patient involvement through self-help groups]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 62: 3-9
• 50 Hundertmark-Mayser J, Möller-Bock B. Selbsthilfe im Gesundheitsbereich. Gesundheitsberichterstattung des Bundes, Heft 23. Herausgegeben vom Robert-Koch-Institut am 1. August 2004. Accessed October 31, 2019 at: http://www.gbe-bund.de/pdf/Heft23.pdf

Publikationsverlauf

Eingereicht: 26. Januar 2021
Eingereicht: 30. Januar 2021

Angenommen: 01. Februar 2021

Artikel online veröffentlicht:
14. April 2021