ESHRE guideline for the diagnosis and treatment of endometriosis
Open accessAbstract
The objective was to develop recommendations for the diagnosis and treatment of endometriosis and its associated symptoms. A working group was convened comprised of practising gynaecologists and experts in evidence-based medicine from Europe, as well as an endometriosis self-help group representative. After reviewing existing evidence-based guidelines and systematic reviews, the expert panel met on three occasions for a day during which the guideline was developed and refined. Recommendations based solely on the clinical experience of the panel were avoided as much as possible. The entire ESHRE Special Interest Group for Endometriosis and Endometrium was given the opportunity to comment on the draft guideline, after which it was available for comment on the ESHRE website for 3 months. The working group then ratified the guideline by unanimous or near-unanimous voting; finally, it was approved by the ESHRE Executive Committee. The guideline will be updated regularly, and will be made available at http://www.endometriosis.org/guidelines.html with hyperlinks to the supporting evidence, and the relevant references and abstracts. For women presenting with symptoms suggestive of endometriosis, a definitive diagnosis of most forms of endometriosis requires visual inspection of the pelvis at laparoscopy as the 'gold standard' investigation. However, pain symptoms suggestive of the disease can be treated without a definitive diagnosis using a therapeutic trial of a hormonal drug to reduce menstrual flow. In women with laparoscopically confirmed disease, suppression of ovarian function for 6 months reduces endometriosis-associated pain; all hormonal drugs studied are equally effective although their side-effects and cost profiles differ. Ablation of endometriotic lesions reduces endometriosis-associated pain and the smallest effect is seen in patients with minimal disease; there is no evidence that also performing laparoscopic uterine nerve ablation (LUNA) is necessary. In minimal-mild endometriosis, suppression of ovarian function to improve fertility is not effective, but ablation of endometriotic lesions plus adhesiolysis is effective compared to diagnostic laparoscopy alone. There is insufficient evidence available to determine whether surgical excision of moderate-severe endometriosis enhances pregnancy rates. IVF is appropriate treatment especially if there are coexisting causes of infertility and/or other treatments have failed, but IVF pregnancy rates are lower in women with endometriosis than in those with tubal infertility. The management of severe/deeply infiltrating endometriosis is complex and referral to a centre with the necessary expertise is strongly recommended. Patient self-help groups can provide invaluable counselling, support and advice.
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Non-steroidal anti-inflammatory drugs frequently fail to relieve pain, including when used alongside lesion surgery or hormone treatment.
“Furthermore, other factors are likely involved because NSAIDs are often ineffective (Allen et al., 2009), even when combined with surgical removal of lesions or hormonal therapy (Kennedy et al., 2005;Appleyard et al., 2006;Ozawa et al., 2006; Practice Committee of the American Society for Reproductive and Medicine, 2008;Vercellini et al., 2009b)”
From Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications (2011) · cites this paper as Kennedy et al., 2005
The guideline’s section A says that a combined oral contraceptive after surgery is not effective, which supports a limited point about pain treatment failing despite surgery and hormonal therapy. It does not say that NSAIDs frequently fail when combined with either treatment; its section C instead says NSAIDs may reduce endometriosis-associated pain. The citing sentence separately attributes the general NSAID-ineffectiveness claim to Allen et al. (2009). (LLM, conf=0.76)
Experimental — accuracy not yet measuredMost endometriosis treatments suppress ovarian function, treating endometriosis as an estrogen-dependent disease.
“Most treatments of endometriosis suppress ovarian function, regarding endometriosis as an estrogen-dependent disease (Kennedy et al., 2005).”
From Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications (2011) · cites this paper as Kennedy et al., 2005
The Evidence level 1b passage says that suppressing ovarian function reduces endometriosis-associated pain and lists several effective hormonal drugs. The guideline also discusses surgical treatment and IVF, so it does not establish that most endometriosis treatments suppress ovarian function. A separate passage cautions about estrogen acting on residual disease, but the guideline does not explicitly characterize endometriosis as an estrogen-dependent disease. (LLM, conf=0.84)
Experimental — accuracy not yet measuredLaparoscopic surgery has enabled surgical diagnosis of endometriosis by confirming lesions and has transformed its surgical treatment.
“Laparoscopic surgery has enabled surgical diagnosis of endometriosis by confirming the existence of lesions and transformed its surgical treatment (Kennedy et al., 2005).”
From Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications (2011) · cites this paper as Kennedy et al., 2005
The Diagnosis section calls visual inspection at laparoscopy the gold standard for definitive diagnosis and says that seeing lesions is usually adequate, although histological confirmation is ideal. The guideline also discusses laparoscopic treatment of lesions, but it does not say that laparoscopy transformed surgical treatment. (LLM, conf=0.86)
Experimental — accuracy not yet measuredHow severe pain is does not track with how extensive the disease is.
“Third, severity of pain symptoms does not correlate with extent of disease (Kennedy et al., 2005;Vercellini et al., 2009b).”
From Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications (2011) · cites this paper as Kennedy et al., 2005
Endometriosis-associated pain is often difficult to alleviate without hormonal treatments that produce often-intolerable side effects of hypoestrogenicity or surgery that frequently fails to help.
“Symptoms include dysmenorrhea, dyspareunia (vaginal hyperalgesia), chronic pelvic/abdominal musculoskeletal and other types of severe pain that are often difficult to alleviate without resorting either to hormonal treatments that produce often-intolerable side effects of hypoestrogenicity or to surgery that frequently fails to help [16,21,27,16,48].”
From Endocannabinoid involvement in endometriosis. (2010) · cites this paper as [27]
Progress in developing new treatment strategies for endometriosis-associated pain is impeded by a poor understanding of how the growths contribute to the pains.
“Although it is recognized that both inflammatory and neuropathic mechanisms contribute to endometriosis-associated pains, progress in developing new treatment strategies is impeded by a poor understanding of how the growths, which do not correlate with the pains, contribute to them [16,21,27,48].”
From Endocannabinoid involvement in endometriosis. (2010) · cites this paper as [27]
The growths do not correlate with the pains.
“Although it is recognized that both inflammatory and neuropathic mechanisms contribute to endometriosis-associated pains, progress in developing new treatment strategies is impeded by a poor understanding of how the growths, which do not correlate with the pains, contribute to them [16,21,27,48].”
From Endocannabinoid involvement in endometriosis. (2010) · cites this paper as [27]
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- Authors
- Kennedy, S., Bergqvist, A., Chapron, C., D’Hooghe, T., Dunselman, G., Greb, R., Hummelshoj, L., Prentice, A., & Saridogan, E.
- Affiliations
- University of Oxford (GB)
- Karolinska Institutet (SE)
- Maastricht University (NL)
- University Hospital Münster (DE)
- University of Cambridge (GB)
- Corresponding author
- Kennedy, Stephen
- Venue
- Human Reproduction
- Publisher
- Oxford University Press (OUP)
- Published
- 2005-06-24
- Volume
- 20
- Issue
- 10
- Pages
- 2698-2704
- ISSN
- 0268-1161 (ISSN-L)
- 1460-2350
- OpenAlex
- W2162317615
- Cited by
- 1,584
- References
- 56
- Citations by year
- 2026: 26 · 2025: 58 · 2024: 67 · 2023: 83 · 2022: 91 · 2021: 73 · 2020: 90 · 2019: 81 · 2018: 68 · 2017: 90 · 2016: 84 · 2015: 84 · 2014: 88 · 2013: 106 · 2012: 97
- FWCI
- 50.82
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Human Reproduction (publishedVersion)
- PubMed (publishedVersion)
- Digital Access to Libraries (submittedVersion)
- Topics
- Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ectopic Pregnancy Diagnosis and Management
- Health Sciences › Medicine › Obstetrics and Gynecology › Gynecological conditions and treatments
- Keywords
- endometriosis, endometriosis treatment, endometriosis-associated pain, ovarian suppression, hormone therapy, adhesiolysis, infertility, in vitro fertilization, deep infiltrating endometriosis, patient self-help groups, dysmenorrhea, dyspareunia
- MeSH terms
- Endometriosis, Europe, Female, Fertilization in Vitro, Humans, Infertility, Female, Laparoscopy, Self-Help Groups, Reproductive Techniques, Assisted
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