New Endometriosis Guidelines May Improve Diagnosis

European health officials just released new guidelines on endometriosis to improve diagnosing and treating the condition—including new recommendations around the use of laparoscopy. 

In February, the European Society of Human Reproduction and Embryology (ESHRE) published more than 100 recommendations and best practices on treating people with endometriosis, a condition where endometrial tissue grows outside of the uterus and causes pain, irregular bleeding, and cramps.

One of the most significant changes involves laparoscopy—a surgical procedure used to diagnose and remove endometriosis. This surgery is no longer considered the gold standard for diagnosis or treatment. These new recommendations replace ESHRE’s 2014 guidelines.

“We made changes in recommendations regarding the relevance of diagnostic laparoscopy with improving imaging techniques—it is now agreed that endometriosis can be diagnosed without laparoscopy—and post-operative hormone therapy, as they could improve the immediate outcome of surgery for pain and could prevent recurrence of disease/symptoms,” Andrew Horne, PhD, a professor of gynecology and reproductive sciences at the University of Edinburgh who was involved in updating the guidelines, told Verywell.

Among other notable updates is a renewed focus on endometriosis and cancer, and, for the first time, there are specific recommendations on evaluating endometriosis in teens. The topics of menopause, pregnancy, and fertility preservation in relation to endometriosis were addressed in more detail, too.

What These Changes Mean

The availability of improved imaging techniques, like ultrasound and MRI, means endometriosis can be diagnosed without the need for laparoscopy, Horne said. If endometriosis lesions are detected with imaging, treatment can start right away.

ESHRE’s patient leaflet about the new guidelines explains, ”A definite diagnosis of endometriosis was previously only considered when the doctor had seen the endometriosis lesions during laparoscopy and confirmed the diagnosis by taking pieces of tissue (biopsies) for microscopic examination (histology).”

The increased ability to spot the condition could lead to a quicker diagnosis and treatment plan, Horne said. “However, the main imaging modalities currently used to assist in diagnosing endometriosis—ultrasound and MRI—both require expertise to perform and interpret,” he added.

But this doesn’t mean surgery will no longer be needed. Laparoscopy will still be required in many circumstances, Horne noted. The guidelines say that laparoscopy should be considered if medical treatment did not work, or if suspected endometriosis couldn’t be detected during imaging. ESHRE also recommends that healthcare providers consider surgery to eliminate lesions when they spot them during laparoscopy for diagnosis.

The focus on diagnosing endometriosis in adolescence in the new guidelines is also very significant, Horne said, because most people report their symptoms started during this time in their lives.

“An early diagnostic procedure in adolescents with untreatable chronic pelvic pain (not responsive to a trial of the oral contraceptive pill) will lead the gynecologist to an early identification of endometriosis, followed by a personalized treatment,” he said. “Given what we know, this seems the best way to guide and protect adolescent girls in these circumstances.”

The Realities of Endometriosis

These European guidelines can act as a blueprint or framework for endometriosis treatment in the U.S., and hopefully lead to improved care.

As it stands, in both the U.S. and elsewhere, diagnosing endometriosis can be a long and painful journey. A 2019 review in the American Journal of Obstetrics and Gynecology found that the time between the onset of symptoms and diagnosis of endometriosis is four to 11 years.

This long time period between experiencing symptoms to diagnosis is often due to an overall lack of awareness of the condition, and limitations in how the condition is diagnosed. Menstrual pain or cramps are often seen as a “normal” part of having your period, Allyson Olivier, the executive director of the Endometriosis Association, told Verywell. This leads to people either feeling like they need to just cope with the pain, as well as healthcare providers underdiagnosing endometriosis.  

“Awareness is such a problem,” Olivier said. “It’s better now than it was, but physicians need to listen to the women when they come into their office with complaints and problems.”

A large part of the association’s work is educating both the public and the medical community about the condition. Olivier says that the Endometriosis Association has a printable pain chart on its website that patients can bring to their healthcare providers. The goal is for patients to use the chart to point to where they are feeling pain so when they talk to their primary care provider or OB-GYN, they can be very specific.

“That tends to help the physicians get a better handle and understand their situation,” Olivier noted. 

There is still much to learn when it comes to endometriosis and treatment options, as patients can respond differently to treatment and have lesions in different parts of their bodies. While the European guidelines are a step in the right direction, the work is not done.

“Surgery is a very important tool in treating endometriosis, but we need to better understand when and how it should be used as part of a more personalized treatment plan,” Horne said. “We need research to find ways to predict which patients (and which subtypes of endometriosis) are likely to respond to surgery and which patients will likely not respond to surgery at all.”