ESHRE guideline: endometriosis

Christian M Becker, Attila Bokor, Oskari Heikinheimo, Andrew Horne, Femke Jansen, Ludwig Kiesel, Kathleen King, Marina Kvaskoff, Annemiek Nap, Katrine Petersen, Ertan Saridogan, Carla Tomassetti, Nehalennia van Hanegem, Nicolas Vulliemoz, Nathalie Vermeulen, ESHRE Endometriosis Guideline Group, Signe Altmäe, Baris Ata, Elizabeth Ball, Fabio Barra, Ercan Bastu, Alexandra Bianco-Anil, Ulla Breth Knudsen, Réka Brubel, Julia Cambitzi, Astrid Cantineau, Ying Cheong, Angelos Daniilidis, Bianca De Bie, Caterina Exacoustos, Simone Ferrero, Tarek Gelbaya, Josepha Goetz-Collinet, Gernot Hudelist, Munawar Hussain, Tereza Indrielle-Kelly, Shaheen Khazali, Sujata Lalit Kumar, Umberto Leone Roberti Maggiore, Jacques W M Maas, Helen McLaughlin, José Metello, Velja Mijatovic, Yasaman Miremadi, Charles Muteshi, Michelle Nisolle, Engin Oral, George Pados, Dana Parades, Nicola Pluchino, Prasanna Raj Supramaniam, Maren Schick, Beata Seeber, Renato Seracchioli, Antonio Simone Laganà, Andreas Stavroulis, Linda Tebache, Gürkan Uncu, Uschi Van den Broeck, Arno van Peperstraten, Attila Vereczkey, Albert Wolthuis, Pınar Yalçın Bahat, Chadi Yazbeck, Christian M Becker, Attila Bokor, Oskari Heikinheimo, Andrew Horne, Femke Jansen, Ludwig Kiesel, Kathleen King, Marina Kvaskoff, Annemiek Nap, Katrine Petersen, Ertan Saridogan, Carla Tomassetti, Nehalennia van Hanegem, Nicolas Vulliemoz, Nathalie Vermeulen, ESHRE Endometriosis Guideline Group, Signe Altmäe, Baris Ata, Elizabeth Ball, Fabio Barra, Ercan Bastu, Alexandra Bianco-Anil, Ulla Breth Knudsen, Réka Brubel, Julia Cambitzi, Astrid Cantineau, Ying Cheong, Angelos Daniilidis, Bianca De Bie, Caterina Exacoustos, Simone Ferrero, Tarek Gelbaya, Josepha Goetz-Collinet, Gernot Hudelist, Munawar Hussain, Tereza Indrielle-Kelly, Shaheen Khazali, Sujata Lalit Kumar, Umberto Leone Roberti Maggiore, Jacques W M Maas, Helen McLaughlin, José Metello, Velja Mijatovic, Yasaman Miremadi, Charles Muteshi, Michelle Nisolle, Engin Oral, George Pados, Dana Parades, Nicola Pluchino, Prasanna Raj Supramaniam, Maren Schick, Beata Seeber, Renato Seracchioli, Antonio Simone Laganà, Andreas Stavroulis, Linda Tebache, Gürkan Uncu, Uschi Van den Broeck, Arno van Peperstraten, Attila Vereczkey, Albert Wolthuis, Pınar Yalçın Bahat, Chadi Yazbeck

Abstract

Study question: How should endometriosis be diagnosed and managed based on the best available evidence from published literature?

Summary answer: The current guideline provides 109 recommendations on diagnosis, treatments for pain and infertility, management of disease recurrence, asymptomatic or extrapelvic disease, endometriosis in adolescents and postmenopausal women, prevention and the association with cancer.

What is known already: Endometriosis is a chronic condition with a plethora of presentations in terms of not only the occurrence of lesions, but also the presence of signs and symptoms. The most important symptoms include pain and infertility.

Study design size duration: The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 1 December 2020 and written in English were included in the literature review.

Participants/materials setting methods: Based on the collected evidence, recommendations were formulated and discussed within specialist subgroups and then presented to the core guideline development group (GDG) until consensus was reached. A stakeholder review was organized after finalization of the draft. The final version was approved by the GDG and the ESHRE Executive Committee.

Main results and the role of chance: This guideline aims to help clinicians to apply best care for women with endometriosis. Although studies mostly focus on women of reproductive age, the guideline also addresses endometriosis in adolescents and postmenopausal women. The guideline outlines the diagnostic process for endometriosis, which challenges laparoscopy and histology as gold standard diagnostic tests. The options for treatment of endometriosis-associated pain symptoms include analgesics, medical treatments and surgery. Non-pharmacological treatments are also discussed. For management of endometriosis-associated infertility, surgical treatment and/or medically assisted reproduction are feasible. While most of the more recent studies confirm previous ESHRE recommendations, there are five topics in which significant changes to recommendations were required and changes in clinical practice are to be expected.

Limitations reasons for caution: The guideline describes different management options but, based on existing evidence, no firm recommendations could be formulated on the most appropriate treatments. Also, for specific clinical issues, such as asymptomatic endometriosis or extrapelvic endometriosis, the evidence is too scarce to make evidence-based recommendations.

Wider implications of the findings: The guideline provides clinicians with clear advice on best practice in endometriosis care, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in endometriosis.

Study funding/competing interests: The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payments. C.M.B. reports grants from Bayer Healthcare and the European Commission; Participation on a Data Safety Monitoring Board or Advisory Board with ObsEva (Data Safety Monitoring Group) and Myovant (Scientific Advisory Group). A.B. reports grants from FEMaLE executive board member and European Commission Horizon 2020 grant; consulting fees from Ethicon Endo Surgery, Medtronic; honoraria for lectures from Ethicon; and support for meeting attendance from Gedeon Richter; A.H. reports grants from MRC, NIHR, CSO, Roche Diagnostics, Astra Zeneca, Ferring; Consulting fees from Roche Diagnostics, Nordic Pharma, Chugai and Benevolent Al Bio Limited all paid to the institution; a pending patent on Serum endometriosis biomarker; he is also Chair of TSC for STOP-OHSS and CERM trials. O.H. reports consulting fees and speaker's fees from Gedeon Richter and Bayer AG; support for attending meetings from Gedeon-Richter, and leadership roles at the Finnish Society for Obstetrics and Gynecology and the Nordic federation of the societies of obstetrics and gynecology. L.K. reports consulting fees from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; honoraria for lectures from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; support for attending meetings from Gedeon Richter, AstraZeneca, Novartis, Dr KADE/Besins, Palleos Healthcare, Roche, Mithra; he also has a leadership role in the German Society of Gynecological Endocrinology (DGGEF). M.K. reports grants from French Foundation for Medical Research (FRM), Australian Ministry of Health, Medical Research Future Fund and French National Cancer Institute; support for meeting attendance from European Society for Gynaecological Endoscopy (ESGE), European Congress on Endometriosis (EEC) and ESHRE; She is an advisory Board Member, FEMaLe Project (Finding Endometriosis Using Machine Learning), Scientific Committee Chair for the French Foundation for Research on Endometriosis and Scientific Committee Chair for the ComPaRe-Endometriosis cohort. A.N. reports grants from Merck SA and Ferring; speaker fees from Merck SA and Ferring; support for meeting attendance from Merck SA; Participation on a Data Safety Monitoring Board or Advisory Board with Nordic Pharma and Merck SA; she also is a board member of medical advisory board, Endometriosis Society, the Netherlands (patients advocacy group) and an executive board member of the World Endometriosis Society. E.S. reports grants from National Institute for Health Research UK, Rosetrees Trust, Barts and the London Charity; Royalties from De Gruyter (book editor); consulting fees from Hologic; speakers fees from Hologic, Johnson & Johnson, Medtronic, Intuitive, Olympus and Karl Storz; Participation in the Medicines for Women's Health Expert Advisory Group with Medicines and Healthcare Products Regulatory Agency (MHRA); he is also Ambassador for the World Endometriosis Society. C.T. reports grants from Merck SA; Consulting fees from Gedeon Richter, Nordic Pharma and Merck SA; speaker fees from Merck SA, all paid to the institution; and support for meeting attendance from Ferring, Gedeon Richter and Merck SA. The other authors have no conflicts of interest to declare.

Disclaimer: This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (Full disclaimer available at www.eshre.eu/guidelines.).

Keywords: ESHRE guideline; adolescent; endometriosis; fertility; guideline; pelvic pain; surgery.

© The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology.

Figures

Figure 1.
Figure 1.
Suggested interpretation of strong and weak recommendations by patients, clinicians and health care policy makers.
Figure 2.
Figure 2.
The recommended diagnostic process for endometriosis. DE, deep endometriosis; US, ultrasound.
Figure 3.
Figure 3.
Summary of the recommendations for treatment of pain symptoms linked to endometriosis. NSAID, non-steroidal anti-inflammatory.
Figure 4.
Figure 4.
Summary of the recommendations on treatment of endometriosis-associated infertility. EFI, endometriosis fertility index; MAR, medically assisted reproduction.
Figure 5.
Figure 5.
Summary of the recommendations and information on endometriosis and pregnancy.
Figure 6.
Figure 6.
Infographic on the absolute risk of developing cancer in a woman’s lifetime.

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