Endometriosis Overview


  • An estrogen-dependent disease wherein endometrial-like tissue is found outside the uterus inducing a chronic inflammatory response 
    •  Pelvic organs (esp ovaries) & peritoneum are frequently affected
  • Main clinical features include chronic pelvic pain, dyspareunia, & infertility
    • However, 2-22% of patients w/ endometriosis may be asymptomatic


Refer to Symptoms for more information




  • Diagnosis of endometriosis is made after taking the patient's history & doing physical examination
    • Laboratory tests, laparoscopy, & imaging studies are performed as well to confirm diagnosis


Refer to Diagnosis for more information




  • Management of endometriosis includes medical therapy w/ first-line agents oral contraceptives & progestins
    • Second-line agents include Danazol, gonadotropin-releasing hormone (GnRH) agonists, Levonorgestrel intrauterine system, & aromatase inhibitors
    • Supportive therapy w/ nonsteroidal anti-inflammatory drugs (NSAIDs) may be given to provide pain relief
  • Surgery should only be done in women w/ endometriosis-related pain after medical treatment has failed
  • Combined medical/surgical therapy is medical therapy given before &/or after surgery


Refer to Treatment for more information on Pharmacological Therapy & Surgery


Below is the overview of disease management of Endometriosis:


overview of management of endometriosis Endometriosis1


follow-up of endometriosis Endometriosis2.png






Endometriosis Symptomsâ–¶

Version: 18 June 2015


Guideline References:

  1. ACOG Committee on Practice Bulletins - Gynecology. Practice bulletin no. 114: management of endometriosis. Obstet Gynecol. 2010 Jul;116(1):223-236. doi: 10.1097/AOG.0b013e3181e8b073. PMID: 20567196
  2. American Society for Reproductive Medicine. Endometriosis. A guide for patients. http://www.asrm.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/endometriosis.pdf. 2012. Accessed 25 Apr 2013.
  3. Attaran M, Falcone T, Goldberg J. Endometriosis: still tough to diagnose and treat. Cleve Clin J Med. 2002 Aug;69(8):647-653. http://www.ncbi.nlm.nih.gov/pubmed/?term=12184473. PMID: 12184473
  4. Beatty MN, Blumenthal PD. The levonorgestrel-releasing intrauterine system: safety, efficacy, and patient acceptability. Ther Clin Risk Manag. 2009 Jun;5(3):561-574. PMID: 19707273
  5. Birmingham A. Treatment of pelvic pain associated with endometriosis. Fertil Steril. 2008;90:561-574. doi: 10.1016/j.fertnstert.2008.08.057.  PMID: 19007642
  6. Bulun SE. Endometriosis. N Engl J Med. 2009;360(3):268-279. doi: 10.1056/NEJMra0804690. PMID: 19144942
  7. Cheng YM, Wang ST, Chou CY. Serum CA-125 in preoperative patients at high risk for endometriosis. Obstet Gynecol. 2002 Mar;99(3):375-380. PMID: 11864662
  8. College National des Gynecologues et Obstetriciens Francais. CNGOF guidelines for the management of endometriosis. http://www.cngof.asso.fr/D_TELE/RPC_endometriose_en_BM.pdf. Nov 2006.
  9. Drake J. Diagnosis and management of the adnexal mass. Am Fam Physician. 1998 May;57(10):2471-2476. PMID: 9614415
  10. Dunselman GA, Vermeulen N, Becker C, et al. ESHRE guideline: management of women with endometriosis. Hum Reprod. 2014 Mar;29(3):400-412. doi: 10.1093/humrep/det457. Accessed 28 Apr 2014. PMID: 24435778
  11. ESHRE Endometriosis Guideline Development Group. Management of women with endometriosis. Guideline of the European Society of Human Reproduction and Embryology [Draft version]. http://www.eshre.eu/binarydata.aspx?type=doc&sessionId=dhxqnrv5jhqpiw45ttwpuxup/ESHRE_ENDOMETRIOSIS_GUIDELINE_Draft_version_for_review.pdf. Apr 2013. Accessed 25 Apr 2013.
  12. European Society of Human Reproduction and Embryology. The ESHRE guideline for the diagnosis and treatment of endometriosis. http://guidelines.endometriosis.org/recommendations.html. Jun 2007.
  13. Farquhar CM. Extracts from the "clinical evidence". Endometriosis. BMJ. 2000 May;320(7247):1449-1452. PMID: 10827052
  14. Fauconnier A, Chapron C. Endometriosis and pelvic pain: epidemiological evidence of the relationship and implications. Hum Reprod Update. 2005;11(6):595-606. PMID: 16172113
  15. Giudice LC. Clinical Practice. Endometriosis. N Engl J Med. 2010 Jun;362(25):2389-2398. doi: 10.1056/NEJMcp1000274. Accessed 06 Feb 2013. PMID: 20573927
  16. Huang HY. Medical treatment of endometriosis. Chang Gung Med J. 2008;31(5):431-440. PMID: 19097589
  17. Kocakoc E, Bhatt S, Droga VS. Endometriosis. Ultrasound Clin. 2008;3:399-414
  18. Kuriyama S, Murakami T, Ozawa Y, et al. Management of the pain associated with endometriosis: an update of the painful problems. Tohoku J Exp Med. 2006 Nov;210(3):175-188. PMID: 17077594
  19. Lapp T. ACOG issues recommendations for the management of endometriosis. Am Fam Physician. 2000 Sep;62(6):1431-1434. http://www.ncbi.nlm.nih.gov/pubmed/?term=11011865. PMID: 11011865
  20. Ling FW. Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis. Pelvic Pain Study Group. Obstet Gynecol. 1999 Jan;93(1):51-58. PMID: 9916956
  21. Lobo RA. Endometriosis: etiology, pathology, diagnosis, management. In: Katz VL, Lentz GM, Lobo RA, Gerhenson DM. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby, Elsevier; 2007
  22. Mishell D, Stenchever M, Droegemuller W, Herbst A. Endometriosis and adenomyosis. In: Stenchever M. Comprehensive Gynecology. 4th ed. St. Louis: Mosby; 2001
  23. Mol BW, Bayram N, Lijmer JG, et al. The performance of CA-125 measurement in the detection of endometriosis: a meta-analysis. Fertil Steril. 1998 Dec;70(6):1101-1108. PMID: 9848302
  24. Moore J, Kennedy S, Prentice A. Modern combined oral contraceptives for pain associated with endometriosis (Cochrane Review). The Cochrane Library, Issue 2. Chichester, UK: John Wiley and Sons, Ltd; 2004
  25. Mounsey AL, Wilgus A, Slawson DC. Diagnosis and management of endometriosis. Am Fam Physician. 2006 Aug;74(4):594-600. PMID: 16939179
  26. Nasir L, Bope ET. Management of pelvic pain from dysmenorrhea or endometriosis. J Am Board Fam Pract. 2004;17(Suppl):S43-S47. PMID: 15575029
  27. National Institute for Health and Care Excellence. Fertility. Assessment and treatment for people with fertility problems. NICE. http://www.nice.org.uk/nicemedia/live/14078/62769/62769.pdf. Feb 2013. Accessed 25 Apr 2013.
  28. Olive DL, Pritts EA. Treatment of endometriosis. N Engl J Med. 2001 Jul;345(4):266-275. PMID: 11474666
  29. Practice Committee of the American Society for Reproductive Medicine. Endometriosis & infertility; a committee opinion. Fertil Steril. 2012 Sep;98(3):591-598. PMID: 22704630
  30. Prentice A, Deary AJ, Goldbeck-Wood S. Gonadotropin-releasing hormone analogues for pain associated with endometriosis (Cochrane Review). The Cochrane Library, Issue 2. Chichester, UK: John Wiley and Sons, Ltd; 2004.
  31. Prentice A. Regular review: endometriosis. BMJ. 2001 Jul;323(7304):93-95. http://www.ncbi.nlm.nih.gov/pubmed/?term=11451786. PMID: 11451786
  32. Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril. 1997 May;67(5):817-821. http://www.ncbi.nlm.nih.gov/pubmed/?term=9130884. PMID: 9130884
  33. Royal College of Obstetricians and Gynaecologists. The investigation and management of endometriosis. Green-top Guideline No. 24. http://www.pelvicpain.org.uk/uploads/documents/InvestigationEndometriosis2006%5B-guidelines.pdf. 2006.
  34. Selak V, Farquhar C, Prentice A. Danazol for pelvic pain associated with endometriosis (Cochrane review). The Cochrane Library, Issue 2. Chichester, UK: John Wiley and Sons, Ltd; 2004
  35. Society of Obstetricians and Gynaecologists of Canada. Endometriosis: diagnosis and management. Journal of Obstetrics and Gynaecology Canada. 2010;32(7):S1-S32. http://www.sogc.org/guidelines/documents/gui244CPG1007E.pdf. PMID: 21545757
  36. Surrey ES, Hornstein MD. Prolonged GnRH agonist and add-back therapy for symptomatic endometriosis: long-term follow-up. Part 1. Obstet Gynecol. 2002 May;99(5)(Pt 1):709-719. PMID: 11978277
  37. Taskin O, Yalcinoglu A, Kucuk S, et al. Effectiveness of tibolone on hypoestrogenic symptoms induced by goserelin treatment in patients with endometriosis. Fertil Steril. 1997 Jan;67(1):40-45. PMID: 8986681
  38. Vercellini P, Trespidi L, Colombo A, et al. A gonadotropin-releasing hormone agonist versus a low-dose oral contraceptive for pelvic pain associated with endometriosis. Fertil Steril. 1993 Jul;60(1):75-79. PMID: 8513962
  39. Wellbery C. Diagnosis and treatment of endometriosis. Am Fam Physician. 1999 Oct;60(6):1753-1768. PMID: 10537390