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ESHRE GUIDELINE for the diagnosis and management of endometriosis

ESHRE GUIDELINE for the diagnosis and management of endometriosis. Thomas M. D’Hooghe, M.D., Ph.D. ESHRE SIG Endometriosis and Endometrium Leuven (Belgium) Postgraduate Course VWRG Leuven, 4 th June 2010. LEARNING OBJECTIVES. At the conclusion of this presentation,

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ESHRE GUIDELINE for the diagnosis and management of endometriosis

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  1. ESHRE GUIDELINE for the diagnosis and management ofendometriosis Thomas M. D’Hooghe, M.D., Ph.D. ESHRE SIG Endometriosis and Endometrium Leuven (Belgium) Postgraduate Course VWRG Leuven, 4th June 2010

  2. LEARNING OBJECTIVES At the conclusion of this presentation, participants should be able to: 1. Summarize the development, updating and level of evidence associated with clinical guidelines in general 2. Apply the ESHRE guidelines for clinical management of endometriosis in their own clinical practice 3. Explain why many clinical issues with respect to endometriosis management are still unresolved and require more and better research.

  3. Guideline Development Group Gerard Dunselmann Maastricht University (NL) Chair 2005-2007 Working party Andrew Prentice University of Cambridge (UK) Chair 2007-2010 Working party Charles Chapron Clinique Universitaire Baudelocque (F) Working party Robert Greb Münster University Hospital (D) Working party Thomas D’Hooghe Leuven University Hospital (B) Working party Daniela Hornung UFK Lübeck (G) Working party Lone Hummelshoj European Endometriosis Alliance (DK) Working party Stephen Kennedy University of Oxford (UK) Working party Ariel Revel University of Jerusalem (IS) Working party Ertan Saridogan University College London (UK) Working party http://guidelines.endometriosis.org

  4. Recommendation: hierarchy of evidence http://guidelines.endometriosis.org

  5. Recommendation:strength of evidence http://guidelines.endometriosis.org

  6. Localization and appearance • Pelvic organs and peritoneum • Minimal to severe (ASRM classification 1996, FS 1997) • Presentation: peritoneal, ovarian, deep • Peritoneal: typical/subtle (red, white, clear) • Ovarian endometriotic cyst/endometrioma • Deeply infiltrative endo (DIE): > 5 mm • Adhesions  frozen pelvis http://guidelines.endometriosis.org

  7. Symptoms • Variable presentation/often asymptomatic • Overlap with other conditions causing pain (IBS, PID, ..) • Delay between onset of symptoms and definitive diagnosis up to 12 years • Typical: severe dysmenorrhea, deep dyspareunia, CPP, cyclical pain associated with bowel or bladder http://guidelines.endometriosis.org

  8. Clinical signs C http://guidelines.endometriosis.org

  9. Diagnosis C http://guidelines.endometriosis.org

  10. Diagnosis - histology GPP http://guidelines.endometriosis.org

  11. Diagnosis - histology GPP GPP http://guidelines.endometriosis.org

  12. Investigations: ultrasound A http://guidelines.endometriosis.org

  13. At present, there is insufficient evidence to indicate that MRI is a useful test to diagnose or exclude endometriosis compared to laparoscopy. Investigations: MRI http://guidelines.endometriosis.org

  14. Investigations: blood tests A http://guidelines.endometriosis.org

  15. Investigations – disease extent GPP http://guidelines.endometriosis.org

  16. Assessment of ovarian cysts GPP http://guidelines.endometriosis.org

  17. Diagnosis - laparoscopy GPP GPP http://guidelines.endometriosis.org

  18. Diagnosis - laparoscopy C C http://guidelines.endometriosis.org

  19. PAIN – empirical w/o diagnosis GPP http://guidelines.endometriosis.org

  20. PAIN (confirmed disease) -NSAIDs A It is important to note that NSAIDs have significant side effects, including gastric ulceration and an anti-ovulatory effect when taken mid-cycle. Other analgesics may be effective but there is insufficient evidence to make recommendations. http://guidelines.endometriosis.org

  21. PAIN -hormonal Tx A There are pilot data suggesting that the aromatase inhibitor, letrozole, may be effective, though there are concerns about bone density loss (Ailawadi et al, 2004). http://guidelines.endometriosis.org

  22. PAIN– duration of GnRH-a Tx A A http://guidelines.endometriosis.org

  23. PAIN – hormonal Treatment The levonorgestrel intrauterine device (LNG IUS) may be effective in reducing endometriosis-associated pain (Vercellini et al, 1999) but there is insufficient evidence to make recommendations. Statement in publication 2005 - adapted in 2006 http://guidelines.endometriosis.org

  24. PAIN – hormonal treatment A A systematic review identified two RCTs and three observational studies, all involving small numbers and a heterogeneous group of patients (Varma R et al, 2005). Nevertheless the evidence suggests that the LNG IUS reduces endometriosis-associated pain (Vercellini et al, 1999; Petta et al, 2005) with symptom control maintained over three years (Lockhat et al, 2005; Lockhat et al, 2004). Statement in revised guidelines 2006 http://guidelines.endometriosis.org

  25. PAIN – HRT C http://guidelines.endometriosis.org

  26. PAIN – surgical treatment A http://guidelines.endometriosis.org

  27. PAIN – surgical treatment Pre-operative treatment A http://guidelines.endometriosis.org

  28. PAIN – surgical treatment Post-operative treatment A http://guidelines.endometriosis.org

  29. INFERTILITY – hormonal treatment A http://guidelines.endometriosis.org

  30. INFERTILITY – surgical treatment A http://guidelines.endometriosis.org

  31. INFERTILITY – surgical treatment B http://guidelines.endometriosis.org

  32. INFERTILITY – surgical treatment A http://guidelines.endometriosis.org

  33. INFERTILITY – surgical treatment Post-operative treatment A http://guidelines.endometriosis.org

  34. INFERTILITY – ART: IUI A http://guidelines.endometriosis.org

  35. INFERTILITY – ART: IVF B A The recommendation above is based on a systematic review but the working group noted that endometriosis does not adversely affect pregnancy rates in some large databases (e.g. SART and HFEA) http://guidelines.endometriosis.org

  36. INFERTILITY – ART: COH for IVF B http://guidelines.endometriosis.org

  37. INFERTILITY – ART: IVF and recurrence risk of endo B http://guidelines.endometriosis.org

  38. INFERTILITY – ART: IVF A http://guidelines.endometriosis.org

  39. INFERTILITY – ART: IVF A http://guidelines.endometriosis.org

  40. INFERTILITY – ART: IVF GPP http://guidelines.endometriosis.org

  41. EXTRAGENITAL ENDOMETRIOSIS B http://guidelines.endometriosis.org

  42. Adolescents: Laparoscopic evaluation of chronic pelvic pain B http://guidelines.endometriosis.org

  43. Adolescents: Laparoscopic Extent and appearance of endo B http://guidelines.endometriosis.org

  44. Adolescents: Obstructive genital anomalies B http://guidelines.endometriosis.org

  45. Coping with disease C http://guidelines.endometriosis.org

  46. Coping with disease GPP GPP http://guidelines.endometriosis.org

  47. http://guidelines.endometriosis.org

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