RCOG World Congress 2023

Diagnosis and management of endometriosis in a District General Hospital

Dr Vedhapriya Sudhakar1, Dr Krishen Sieunarine2

1 Specialty Registrar, Obstetrics and Gynaecology, 2Consultant Obstetrics and Gynaecology, Kettering General Hospital

Audit Question

Are the cases with suspected and diagnosed cases of endometriosis managed appropriately as per NICE guidance in a District general hospital?

Main Answer

This audit shows the complete adherence of hospital protocol to the NICE guidelines and the involvement of multidisciplinary team with appropriate management or referral in moderate to severe cases.

Background

Endometriosis is a chronic oestrogen-dependent gynaecological condition characterized by progressive and invasive endometriotic growth affecting up to 10%–15% of women in reproductive-age. It is one of the most common causes of chronic pelvic pain.

Objective

This service evaluation describes the management of suspected and previously diagnosed cases of endometriosis, when presenting to the outpatient setting, to help outline management pathways in a district general hospital and its adherence to the NICE Endometriosis guideline 73.

Methods

Retrospective data collection over a 12-month period from January to December 2021 using the letters stored in Secretary’s folder specific to the patients attending the outpatient setting to a consultant with a specialist interest in endometriosis was done. Keywords such as pelvic pain, endometriosis, theatre were used to narrow the number of patient’s letters with suspected/diagnosed endometriosis.

INCLUSION CRITERIA: Women presenting with a new episode in the outpatient gynaecology setting for suspected new and recurrent cases of endometriosis.

EXCLUSION CRITERIA: Patients with ongoing management for endometriosis , Patients diagnosed with endometriosis on acute setting, Incidental finding of endometriosis and being asymptomatic.

In this time period following referrals from GP , 21 patients with newly suspected endometriosis and 21 known endometriosis patients, presenting with a new episode of recurrence were included and followed up to 1 year after discharge from hospital.

RESULTS :

•Most common age group of presentation in newly suspected cases was 18-25 years (43%) and in recurrent group was 36-44 years (52%) with 52% and 38% been nulliparous in respective groups.

•13/21 patients (62%) received treatment in primary care either as a part of the pelvic pain management or contraception along with analgesics. In recurrent cases, all patients were directly referred to gynecology.

•Patients in both the groups had either abdominal/ pelvic examination, ultrasound and/or CA-125 as basic workup.

Group 1 – New cases of suspected endometriosis

•The first line of management waslaparoscopy(57%) followed by hormonal (33%) and GnRH agonist (10%). Eventually, 7 out of 10 women underwent laparoscopy with 93% diagnosed with endometriosis during surgery. 8 out of 10 women diagnosed, were treated with disease excision and underwent follow up management.( Figure 3)

•Overall follow-up, shown in Figure 4 highlights successful discharge of 8 in 10 women back to primary care with appropriate management.

Group 2– New episode of recurrence in a diagnosed case of endometriosis

•Previous diagnosis and treatment as described infigure 5

•Majority treated with GnRH agonist as the first line management (58%,12/21), followed by hormonal management, (28% ,6/21) and laparoscopy(21%, 3/21). Eventually, 8 in 10 women underwent laparoscopy in total. Among them, disease excision with long term medical management or pelvic clearance was done in 88% of cases.

•7 out of 10 women were successfully discharged to primary care after treatment and the rest were referred to higher center.(Figure 6)

Conclusion(s):

•This service evaluation concludes that patients have been treated as per NICE guidance( Examination, investigation, management, referral pathway).

•Patients with suspected endometriosis should be offered either medical or surgical management to diagnose and treat endometriosis.

•Suppression of disease with appropriate medical management post surgery contributes to treatment success and is important to reduce recurrence if not planning for pregnancy.

•GnRH agonist treatment in known endometriotic patients should be considered before offering pelvic clearance surgery, to ensure symptoms are caused by the suspected pathology.

RCOG World Congress 2023

Management of endometriosis cases in a district general hospital

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