Geburtshilfe Frauenheilkd 2021; 81(04): 422-446
DOI: 10.1055/a-1380-3693
GebFra Science
Guideline/Leitlinie

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

Article in several languages: English | deutsch
Stefanie Burghaus
1   Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Germany
,
Sebastian D. Schäfer
2   Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Münster, Münster, Germany
,
Matthias W. Beckmann
1   Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Germany
,
Iris Brandes
3   Institut für Epidemiologie, Sozialmedizin und Gesundheitssystemforschung, Medizinische Hochschule Hannover, Hannover, Germany
,
Christian Brünahl
4   Institut für Psychosomatische Medizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
,
Radek Chvatal
5   AKH Znojmo, Znojmo, Czech Republic
,
Jan Drahoňovský
6   UPMD Prag, Prag, Czech Republic
,
Wojciech Dudek
7   Thoraxchirurgie, Universitätsklinikum Erlangen, Erlangen, Germany
,
Andreas D. Ebert
8   Praxis für Frauengesundheit, Gynäkologie & Geburtshilfe, Berlin, Germany
,
Christine Fahlbusch
1   Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Germany
,
Tanja Fehm
9   Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
,
Peter Martin Fehr
10   Frauenklinik, Kantonsspital Graubünden, Chur, Switzerland
,
Carolin C. Hack
1   Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Germany
,
Winfried Häuser
11   Klinik für Innere Medizin 1 (Gastroenterologie, Hepatologie, Onkologie, Stoffwechsel- und Infektionskrankheiten, Psychosomatik), Klinikum Saarbrücken gGmbH, Saarbrücken, Germany
,
Katharina Hancke
12   Frauenklinik, Universitätsklinikum Ulm, Ulm, Germany
,
Volker Heinecke
13   Frauenarztpraxis, Bad Urach, Germany
,
Lars-Christian Horn
14   Institut für Pathologie, Universitätsklinikum Leipzig, Leipzig, Germany
,
Christian Houbois
15   Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Köln, Köln, Germany
,
Christine Klapp
16   Ärztliche Gesellschaft zur Gesundheitsförderung e. V. Hamburg, Charité – Universitätsmedizin Berlin Klinik für Geburtsmedizin, Berlin, Germany
,
Heike Kramer
17   Ärztliche Gesellschaft zur Gesundheitsförderung e. V. Hamburg, Spardorf, Germany
,
Harald Krentel
18   Klinik für Frauenheilkunde, Geburtshilfe, Gynäkologische Onkologie und Senologie, Ev. Krankenhaus BETHESDA, Duisburg, Germany
,
Jan Langrehr
19   Allgemein-, Gefäß- und Viszeralchirurgie, Martin Luther Krankenhaus, Berlin, Germany
,
Heike Matuschewski
20   Endometriose-Vereinigung Deutschland e. V., Leipzig, Germany
,
Ines Mayer
21   EVA – Endometriose Vereinigung Austria e. V., Wien, Austria
,
Sylvia Mechsner
22   Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin, Berlin, Germany
,
Andreas Müller
23   Frauenklinik, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
,
Armelle Müller
21   EVA – Endometriose Vereinigung Austria e. V., Wien, Austria
,
Michael Müller
24   Universitätsklinik für Frauenheilkunde, Universitätsspital Bern, Bern, Switzerland
,
Peter Oppelt
25   Universitätsklinik für Gynäkologie, Geburtshilfe und Gynäkologische Endokrinologie, Kepler Universitätsklinikum, Linz, Austria
,
Thomas Papathemelis
26   Klinik für Frauenheilkunde, Klinikum St. Marien Amberg, Amberg, Germany
,
Stefan P. Renner
27   Klinik für Frauenheilkunde und Geburtshilfe, Kliniken Böblingen, Böblingen, Germany
,
Dietmar Schmidt
28   MVZ für Histologie, Zytologie und molekulare Diagnostik, Trier, Germany
,
Andreas Schüring
29   MVZ KITZ Regensburg GmbH, Regensburg, Germany
,
Karl-Werner Schweppe
30   Vorstand der Stiftung Endometriose-Forschung, Westerstede, Germany
,
Beata Seeber
31   Universitätsklinik für Gynäkologische Endokrinologie und Reproduktionsmedizin, Department Frauenheilkunde, Innsbruck, Austria
,
Friederike Siedentopf
32   Praxis für Brusterkrankungen, goMedus Gesundheitszentrum, Berlin, Germany
,
Horia Sirbu
7   Thoraxchirurgie, Universitätsklinikum Erlangen, Erlangen, Germany
,
Daniela Soeffge
20   Endometriose-Vereinigung Deutschland e. V., Leipzig, Germany
,
Kerstin Weidner
33   Klinik und Poliklinik für Psychotherapie und Psychosomatik, Medizinische Fakultät Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
,
Isabella Zraik
34   Urologie, KEM | Evang. Kliniken Essen-Mitte, Essen, Germany
,
Uwe Andreas Ulrich
35   Klinik für Gynäkologie und Geburtshilfe, Martin Luther Krankenhaus, Berlin, Germany
› Author Affiliations
 

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.


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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.


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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


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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


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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.


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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.


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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
 


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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.


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Area of patient care

Inpatient, outpatient and day-care sector.


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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.


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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.


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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.


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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


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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.


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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


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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.


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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.

Consensus-based statement 1.S1

Expert consensus

Strength of consensus +++

Reliable data on the prevalence and incidence of endometriosis are not available.

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].

Consensus-based statement 1.S2

Expert consensus

Strength of consensus +++

Because of the unclear aetiology of endometriosis, causal therapy is not possible.

Reference: [8]

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


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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.

Consensus-based recommendation 2.E1

Expert consensus

Strength of consensus ++

If an intraoperative diagnosis of endometriosis is suspected, the diagnosis must be confirmed histologically.

Consensus-based recommendation 2.E2

Expert consensus

Strength of consensus ++

The rASRM score (version 1996) must be documented at all operations on patients with a suspected diagnosis of endometriosis.

Consensus-based recommendation 2.E3

Expert consensus

Strength of consensus +++

The Enzian classification (version 2011) must be used in patients with deep infiltrating endometriosis including uterine adenomyosis.

Consensus-based statement 2.S3

Expert consensus

Strength of consensus +++

The symptoms pain and infertility are not recorded with the rASRM score and the Enzian classification. The classifications also do not predict the course of the disease.


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2.2  Histological classification of endometriosis

Consensus-based statement 2.S4

Expert consensus

Strength of consensus ++

Endometriosis is the occurrence of endometrium-like groups of cells consisting of groups of endometrioid glandular cells and/or stromal cells outside the uterine cavity.

Consensus-based recommendation 2.E4

Expert consensus

Strength of consensus +++

The primary histological diagnosis of endometriosis is made by haematoxylin-eosin staining. If histological diagnosis of macroscopically suspected endometriosis is negative, additional tests (e.g., additional sections, CD10 or haemosiderin staining) should be performed.

Consensus-based statement 2.S5

Expert consensus

Strength of consensus +++

Endometriosis of the body of the uterus (clinically: adenomyosis or uterine adenomyosis or internal genital endometriosis) is defined histopathologically as the finding of a focus of endometriosis in the myometrium at a distance from the endo-myometrial boundary at medium magnification (100 ×) equivalent metrically to 2.5 mm.

References: [9], [10], [11]

Consensus-based recommendation 2.E5

Expert consensus

Strength of consensus +++

In bowel specimens resected because of deep infiltrating endometriosis involving bowel, a statement about the resection margin status must be made in the histopathological report.


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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.


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

Consensus-based recommendation 3.E6

Expert consensus

Strength of consensus ++

Endometriosis-specific symptoms (dysmenorrhoea, dysuria, dyschezia, dyspareunia and infertility) and nonspecific symptoms such as pelvic pain must be recorded when taking a gynaecological history. This can be done with a specific endometriosis questionnaire.

Reference: [12]

Consensus-based recommendation 3.E7

Expert consensus

Strength of consensus +++

If deep infiltrating endometriosis or ovarian endometriosis is suspected, bilateral renal ultrasound must be performed.

Reference: [13]

Consensus-based statement 3.S6

Expert consensus

Strength of consensus +++

Laparoscopy with intraoperative biopsy for histological examination is the gold standard to confirm a suspected diagnosis of endometriosis.

References: [8], [14]

Consensus-based statement 3.S7

Expert consensus

Strength of consensus +++

Biomarkers are not suitable for the diagnosis of endometriosis.

Reference: [8]


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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.

Consensus-based recommendation 4.E8

Expert consensus

Strength of consensus +++

A suitable progestin (e.g., dienogest) should be used as first-line drug in the symptomatic pharmacological treatment of endometriosis.

Consensus-based recommendation 4.E9

Expert consensus

Strength of consensus ++ to +++

  1. Combined oral contraceptives (strength of consensus ++)

  2. Other progestins including topical use (strength of consensus +++) or

  3. GnRH analogues (strength of consensus ++)

can be used as second-line treatment.

Consensus-based recommendation 4.E10

Expert consensus

Strength of consensus ++

Before starting second-line treatment, re-evaluation in a facility specialising in the care of patients with endometriosis should be considered.

Consensus-based recommendation 4.E11

Expert consensus

Strength of consensus +++

Treatment with GnRH analogues should be supplemented by add-back treatment with a suitable oestrogen-progestin combination. The consequences of oestrogen deficiency can thereby be minimised without influencing the therapeutic efficacy of the GnRH analogue.

References: [15], [16]

Consensus-based statement 4.S8

Expert consensus

Strength of consensus +++

Long-term hormonal therapy used continuously is effective both in the treatment of endometriosis-associated symptoms and for prolonging the recurrence-free interval.

Reference: [8]

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.


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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].


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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].


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4.3  Surgical treatment of endometriosis

Consensus-based recommendation 4.E12

Expert consensus

Strength of consensus +++

In the symptomatic patient with deep infiltrating endometriosis, complete resection should be attempted if the expected benefits of pain reduction outweigh the disadvantages of possible operation-related organ impairment (e.g., sexuality and disorders of bladder, bowel, sensory and motor function).

Reference: [17]

Consensus-based recommendation 4.E13

Expert consensus

Strength of consensus +++

For recurrent symptoms, pharmacological treatment should be given before further surgical treatment unless there are compelling reasons for surgery (e.g., organ destruction).

Reference: [17]


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5  Care structures for patients with suspected or confirmed endometriosis

Consensus-based recommendation 5.E14

Expert consensus

Strength of consensus +++

Patients with endometriosis should be treated by an interdisciplinary team. This team should include all necessary specialties in a cross-sector network. This can be achieved in a certified structure (clinic, centre) ([Fig. 1]).

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

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6  Diagnosis and treatment of endometriosis according to site

6.1  Endometriosis of the uterus (N80.0)

Consensus-based recommendation 6.E15

Expert consensus

Strength of consensus +++

The suspected diagnosis adenomyosis of the uterus can be made by transvaginal sonography and/or MRI. Transvaginal sonography must be used as first-line diagnostic investigation, and MRI as second-line investigation. Both methods are equivalent as regards their reliability.

Consensus-based recommendation 6.E16

Expert consensus

Strength of consensus ++

Because of the limited sensitivity and specificity of biopsy-based confirmation of adenomyosis of the uterus, a biopsy should not be done.

Consensus-based statement 6.S9

Expert consensus

Strength of consensus +++

All established forms of hormone therapy (combined oral contraceptives, progestins, suitable progestin IUD, GnRH analogues) are effective in the treatment of adenomyosis-associated symptoms. There is no evidence that one substance class is superior.

Consensus-based recommendation 6.E17

Expert consensus

Strength of consensus +++

Interventional treatment with high-frequency ultrasound (HIFU), uterine artery embolisation (UAE), transcervical electroablation, percutaneous microwave ablation (PMWA) to treat adenomyosis of the uterus must be used only in studies.

Consensus-based recommendation 6.E18

Expert consensus

Strength of consensus +++

Cystic or focal adenomyosis of the uterus can be resected for control of pain and bleeding.

Consensus-based recommendation 6.E19

Expert consensus

Strength of consensus +++

Hysterectomy can be recommended for symptoms of adenomyosis of the uterus when family planning is complete.

Reference: based on the S3 guideline “Indication and method of hysterectomy for benign disease” in version 1.0 April 2015, AWMF no. 015/070 with weakening of the level of recommendation.


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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].

Consensus-based recommendation 6.E20

Expert consensus

Strength of consensus ++

Before determining the treatment strategy for ovarian endometriosis, anti-Müllerian hormone can be measured as a marker of ovarian reserve.

Consensus-based recommendation 6.E21

Expert consensus

Strength of consensus +++

Ovarian function must be considered when deciding on the treatment of endometriomas.

Consensus-based statement 6.S10

Expert consensus

Strength of consensus +++

When endometriomas are removed in cases of recurrence, there is an increased risk for premature loss of ovarian function.

Consensus-based statement 6.S11

Expert consensus

Strength of consensus +++

All known operative procedures for endometriomas reduce ovarian reserve.

Consensus-based recommendation 6.E22

Expert consensus

Strength of consensus +++

When an endometrioma is diagnosed, the simultaneous presence of deep infiltrating endometriosis should be excluded.

Consensus-based recommendation 6.E23

Expert consensus

Strength of consensus +++

Transvaginal sonography must be used to assess the ovaries when endometriosis is confirmed or suspected.

Consensus-based recommendation 6.E24

Expert consensus

Strength of consensus +++

If the result of sonography of the ovary is suspicious, the surgical histological diagnosis must be confirmed observing oncological safety.

Consensus-based recommendation 6.E25

Expert consensus

Strength of consensus +++

To prevent endometrioma recurrence, systemic hormone therapy (preferably with COC) can be used long-term.

Consensus-based statement 6.S12

Expert consensus

Strength of consensus +++

With primary surgical treatment of an endometrioma, complete removal compared with fenestration of the ovary increases the spontaneous pregnancy rate and is superior to pharmacological treatment with regard to pain reduction and avoidance of recurrence.

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


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

Consensus-based recommendation 6.E26

Expert consensus

Strength of consensus ++

If symptomatic peritoneal endometriosis is diagnosed intraoperatively, primary complete removal should be attempted. Planned second-look laparoscopy with or without pretreatment must not be performed.

Consensus-based statement 6.S13

Expert consensus

Strength of consensus +++

Ablation and excision of peritoneal endometriosis are equivalent with regard to pain reduction.

Reference: [24]

Consensus-based statement 6.S14

Expert consensus

Strength of consensus +++

Surgical removal of peritoneal endometriosis leads to a significant reduction in the severity of dysmenorrhoea on the visual analogue scale (VAS). This effect was not shown for chronic pelvic pain, dyschezia and dyspareunia when peritoneal endometriosis was removed surgically.

Reference: [24]


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

Consensus-based recommendation 6.E27

Expert consensus

Strength of consensus +++

For symptomatic endometriosis of the rectovaginal septum and vagina, function-adapted complete resection should be performed.

Consensus-based recommendation 6.E28

Expert consensus

Strength of consensus +++

Asymptomatic endometriosis of the rectovaginal septum and vagina without currently foreseeable, clinically significant secondary consequences (e.g., obstructive uropathy) does not have to be treated.


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6.5  Endometriosis of the bowel (N80.5)

Consensus-based recommendation 6.E29

Expert consensus

Strength of consensus +++

A patient with haematochezia must have differential diagnostic investigations.

Consensus-based statement 6.S15

Expert consensus

Strength of consensus +++

An asymptomatic patient with bowel endometriosis does not require any surgical intervention.

Consensus-based recommendation 6.E30

Expert consensus

Strength of consensus +++

A patient with bowel endometriosis must be treated in interdisciplinary consensus, in certified facilities as far as possible.

Consensus-based recommendation 6.E31

Expert consensus

Strength of consensus +++

In patients with endometriosis of the bowel renal sonography must be performed in the case of conservative treatment or pre- and postoperatively so as not to overlook clinically silent hydronephrosis.


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6.6  Endometriosis in a skin scar (N80.6)

Consensus-based statement 6.S16

Expert consensus

Strength of consensus +++

Surgical removal of an endometriosis lesion in a skin scar leads to symptom control and is the treatment of choice.


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

Consensus-based statement 6.S17

Expert consensus

Strength of consensus ++

Endometriosis of the bladder and/or ureter can have serious consequences, such as obstructive uropathy with potential consequent loss of renal function.

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.


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

Consensus-based recommendation 6.E32

Expert consensus

Strength of consensus ++

Symptomatic abdominal wall or umbilical endometriosis should be removed surgically.

Consensus-based recommendation 6.E33

Expert consensus

Strength of consensus +++

For thoracic endometriosis and/or endometriosis-associated pneumothorax (including catamenial pneumothorax), conservative pharmacological measures should be used initially. If medical treatment fails or is contraindicated, thoracic surgery must be performed.


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7  Special endometriosis situations

7.1  Endometriosis in adolescents

Consensus-based statement 7.S18

Expert consensus

Strength of consensus +++

All forms of persistent pelvic pain (dysmenorrhoea, cyclical and non-cyclical pelvic pain) in adolescence can be symptoms of endometriosis.

Consensus-based recommendation 7.E34

Expert consensus

Strength of consensus ++

The primary treatment of suspected endometriosis in adolescence should be conservative pharmacological treatment.

Consensus-based recommendation 7.E35

Expert consensus

Strength of consensus ++

For refractory pain, laparoscopy should be performed to investigate the symptoms and, if applicable, remove any endometriosis, if possible in the same procedure.


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7.2  Endometriosis and desire for children

Consensus-based recommendation 7.E36

Expert consensus

Strength of consensus +++

Women with histologically confirmed endometriosis should be informed about the possibly impaired chances of pregnancy.

Consensus-based recommendation 7.E37

Expert consensus

Strength of consensus ++

For patients with infertility and endometriomas, treatment should be determined in an interdisciplinary setting in collaboration with a reproductive medicine centre.


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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]

Consensus-based statement 7.S19

Expert consensus

Strength of consensus ++

Treated or existing deep infiltrating endometriosis is not a contraindication to spontaneous delivery.

Consensus-based recommendation 7.E38

Expert consensus

Strength of consensus +++

In the case of existing or resected rectal endometriosis, no recommendation for a certain mode of delivery (i.e., spontaneous delivery versus section) can be expressed.

Consensus-based statement 7.S20

Expert consensus

Strength of consensus +++

Surgical treatment of deep infiltrating endometriosis in the region of the sigmoid, appendix/caecum, ileum or colon is not an indication for primary section.


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7.4  Endometriosis and pain

Consensus-based recommendation 7.E39

Expert consensus

Strength of consensus +++

In patients with endometriosis and refractory chronic pelvic pain, a structured pain history must be taken.

References: [35], [36]

Consensus-based recommendation 7.E40

Expert consensus

Strength of consensus ++

In patients with chronic pelvic pain, symptom-guided pain therapy can be considered in the following situations:

  • Insufficient pain reduction and/or

  • Intolerance and/or

  • Contraindications to surgical or hormonal therapy.


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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].

Consensus-based recommendation 7.E41

Expert consensus

Strength of consensus +++

The terminology and morphological diagnosis of endometriosis-associated cancer must be based on the current version of the WHO classification.

Consensus-based recommendation 7.E42

Expert consensus

Strength of consensus +++

The surgical treatment concept for patients with endometriosis in the premenopause should not be influenced by the slightly increased ovarian cancer risk.


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7.6  Endometriosis and psychosomatic aspects

Consensus-based recommendation 7.E43

Expert consensus

Strength of consensus +++

Primary psychological assessment for anxiety and depression in patients with endometriosis should take place in the context of basic psychosomatic care.

Consensus-based recommendation 7.E44

Expert consensus

Strength of consensus ++

Patients with endometriosis and high stress due to mental symptoms must be offered psychotherapy, if possible within a multimodal treatment concept.

Consensus-based statement 7.S21

Expert consensus

Strength of consensus +++

Endometriosis can be associated with mental disorders such as increased anxiety and/or depression.

References: [41], [42], [43]


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7.7  Endometriosis and association with other diseases

Consensus-based statement 7.S22

Expert consensus

Strength of consensus +++

Endometriosis can be associated with other chronic pain syndromes (e.g., irritable bowel syndrome, bladder pain syndrome, fibromyalgia syndrome).

References: [44], [45], [46]

Consensus-based recommendation 7.E45

Expert consensus

Strength of consensus +++

Patients with endometriosis and chronic pelvic pain must be investigated for the presence of other chronic pain syndromes.

Consensus-based recommendation 7.E46

Expert consensus

Strength of consensus ++

In the gynaecological examination, local (myofascial trigger points) and generalised hyperalgesia and increased pain sensitivity (allodynia) as evidence for central sensitisation must be noted.

Consensus-based recommendation 7.E47

Expert consensus

Strength of consensus +++

In patients with endometriosis and associated pain syndromes, treatment options must be discussed with pain therapists and physicians specialising in psychosomatic medicine and psychotherapy or psychological psychotherapists.


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8  Rehabilitation, follow-up care and self-help

Consensus-based recommendation 8.E48

Expert consensus

Strength of consensus +++

Rehabilitation/follow-up treatment for women with endometriosis should take place in a rehabilitation clinic certified for this disease.

Reference: [47]

Consensus-based statement 8.S23

Expert consensus

Strength of consensus +++

Women with endometriosis must be informed of the services provided by the pension insurance organisations for rehabilitation and follow-up care.

Reference: [48]

Consensus-based recommendation 8.E49

Expert consensus

Strength of consensus +++

To deal with the physical and mental problems that can affect women with endometriosis, patients must be informed about self-help services.

References: [49], [50]

Consensus-based recommendation 8.E50

Expert consensus

Strength of consensus +++

The participation of women with endometriosis in structured educational or information events should be encouraged and supported.

References: [49], [50]


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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.

Consensus-based recommendation 9.E51

Expert consensus

Strength of consensus ++

Endometriosis patients should be asked about the use of complementary medicine and alternative methods and advised if they wish.

Consensus-based recommendation 9.E52

Expert consensus

Strength of consensus +++

Patients who use such methods must be informed of possible risks and, where applicable, interactions with standard treatments.


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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.


Correspondence/Korrespondenzadresse

PD Dr. med. habil. Stefanie Burghaus
Frauenklinik
Universitätsklinikum Erlangen
Universitätsstraße 21 – 23
91054 Erlangen
Germany   

Publication History

Received: 26 January 2021
Received: 30 January 2021

Accepted: 01 February 2021

Article published online:
14 April 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


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Abb. 1 Agreed care algorithm of the guideline group (based on expert consensus, strength of consensus ++).
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Abb. 1 Konsentierter Versorgungsalgorithmus der Leitliniengruppe (basierend auf Expertenkonsens, Konsensusstärke ++).
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