The diagnosis and management of endometriosis

Endometriosis is a chronic inflammatory disease defined as the presence of endometrium-like tissue outside the uterus.¹ Establishment and growth of such endometriotic tissue is estrogen-dependent ², thus it is mostly found in women of reproductive age although the clinical consequences of endometriosis and its management can last well into post-menopause. The exact prevalence of endometriosis is unknown, but estimates range from 2 to 10% within the general female population but up to 50% in infertile women.^{3, 4} Thus, it is estimated that currently at least 190 million women and adolescent girls worldwide are affected by the disease during reproductive age although some women may suffer beyond menopause.^{5, 6} Whilst not all women with endometriosis are symptomatic, endometriosis-associated pain and infertility are the clinical hallmarks of the disease affecting not only women with endometriosis, but also their partners and families. An impact of endometriosis, and particularly pain symptoms, has been shown on quality of life, but also on a range of activities and life domains including physical functioning, everyday activities and social life, education and work, sex, intimacy and intimate partnerships, and mental health and emotional wellbeing.⁷ The same review also reported an impact of infertility and concerns about possible infertility on the patient and the relationship with their partner.⁷ Finally, endometriosis has a bearing on society in general e.g. through direct and indirect healthcare costs which are comparable to other common diseases such as type 2 diabetes, rheumatoid arthritis, and Crohn’s disease.⁸ Despite all of this, there still exists a large diagnostic void between the onset of symptoms and a reliable diagnosis averaging between 8-12 years. Therapeutic options range from improving pain symptoms and fertility prospects by means of hormone suppression of endogenous estrogen levels, pro-apoptotic and anti-inflammatory effects on endometriotic tissue, surgical removal, or destruction of endometriotic lesions and division of adhesions to management of chronic pain syndromes

Whilst there still exists a great unmet clinical need for improving many aspects of the diagnosis of the disease and the treatment of endometriosis-associated symptoms, there is a slowly growing body of studies which found the basis for the use of evidence-based recommendations which are compiled here.