Endometriosis, or more particularly diagnosis of endometriosis is often a challenge in general practice. When should you start investigating a young girl with painful periods? Is it worth investigating or should we just put them on the Pill? At what point should these young women be referred? Consequently, the most recent NICE guidelines on the diagnosis and management of endometriosis, published in the BMJ will be of interest to any GP who manages young women. According to the UK guidelines, there is commonly a delay of up to 10 years between the development of symptoms and the diagnosis of endometriosis, despite the condition affecting an estimated 10% of women in the reproductive age group. Endometriosis should be suspected in women who have one or more of the following symptoms:

• chronic pelvic pain
• period pain that is severe enough to affect their activities
• deep pain associated with or just after sex
• period-related bowel symptoms such as painful bowel movements
• period-related urinary symptoms such as dysuria or even haematuria

Sometimes it can be worthwhile to get the patient to keep a symptom diary especially if they are unsure if their symptoms are indeed cyclical. Women who present with infertility and a history of one or more of these symptoms should also be suspected as having endometriosis.

Investigations

With regard investigations, the guidelines importantly state that endometriosis cannot be ruled out by a normal examination and pelvic ultrasound. Nonetheless after abdominal and pelvic examination, transvaginal ultrasound should be the first investigation to identify endometriomas and deep endometriosis that has affected other organs such as the bowel or bladder. Transabdominal ultrasounds are a worthwhile alternative in women for whom a transvaginal ultrasound is not appropriate. MRI might be appropriate as a second line investigation but only to determine the extent of the disease. It should not be used for initial diagnosis. Similarly, the serum CA-125 is an inappropriate and unreliable diagnostic test. Diagnostic laparoscopy is reserved for women with suspected endometriosis who have a normal ultrasound.

Treatment

If the symptoms of endometriosis can’t be adequately controlled with analgesia, the guidelines recommend hormonal treatment with either the combined oral contraceptive pill or progestogen. Women need to be aware that this will reduce pain and will have no permanent negative effect on fertility. Surgical options to treat endometriosis need to be considered in women whose symptoms remain intolerable despite hormonal treatment, if the endometriosis is extensive involving other organs or if fertility is a priority and it is suspected that the endometriosis might be affecting the woman’s ability to fall pregnant. All in all, these guidelines from the Royal College of Obstetricians and Gynaecologists don’t offer much in the way of new treatments but they do provide a framework to help GPs manage suspected cases of endometriosis and hopefully reduce that time delay between symptom-onset and diagnosis. BMJ 2017; 358: j3935 doi: 10.1136/bmj.j3935