When to suspect endometriosis and initial mx steps in primary care?

Endometriosis should be suspected in women presenting with symptoms such as chronic pelvic pain, period-related pain affecting daily activities, deep pain during or after sexual intercourse, cyclical gastrointestinal symptoms like painful bowel movements, cyclical urinary symptoms such as blood in the urine or pain passing urine, and infertility associated with these symptoms ¹.

Women with suspected endometriosis should be asked about any family history of the condition, as this increases the likelihood of endometriosis ².

Initial management in primary care includes offering a transvaginal ultrasound scan to all women with suspected endometriosis, even if the pelvic or abdominal examination is normal, to identify ovarian endometriomas and deep endometriosis, and to guide referral and management ¹.

If a transvaginal ultrasound is declined or not suitable, consider a transabdominal ultrasound scan of the pelvis ¹.

Management of pain involves a short trial (e.g., 3 months) of paracetamol and/or NSAIDs for first-line treatment, discussing benefits and risks with the woman ¹.

Hormonal treatments, such as combined oral contraceptive pills or progestogens, can be offered to reduce endometriosis-related pain and do not negatively affect fertility ¹.

Women should be advised on non-pharmacological management, noting that evidence does not support Chinese herbal medicines or supplements for treatment ¹.

If initial treatment is ineffective, not tolerated, or contraindicated, or if symptoms significantly impact daily life, referral to a gynaecology service or specialist endometriosis service should be considered for further investigation and management, including possible laparoscopy ¹.