Resumo do NICE
As recomendações neste tópico do Best Practice são baseadas em diretrizes internacionais autorizadas, complementadas por evidências e opiniões de especialistas relevantes para a prática recentes. Para seu maior benefício resumimos abaixo as principais recomendações das diretrizes do NICE relevantes.
Principais recomendações do NICE sobre diagnóstico
Suspect endometriosis in women (including those aged under 18 years) presenting with 1 or more of the following:
Chronic pelvic pain (i.e., pelvic pain lasting for 6 months or more)
Dysmenorrhoea affecting functioning and quality of life
Deep pain associated with sexual intercourse
Period-related or cyclical gastrointestinal symptoms, in particular, painful bowel movements
Period-related or cyclical urinary symptoms, in particular, blood in the urine or pain passing urine
Infertility in association with 1 or more of the above.
Ask if any first-degree relatives have a history of endometriosis, as this increases the likelihood of endometriosis.
Discuss keeping a pain and symptom diary.
Consider that the person’s experience of pain is unique to them and may be expressed in different ways, both verbally and non-verbally (and in particular, may vary with cultural background, beliefs, socioeconomic status and neurodiversity).
Offer an abdominal and pelvic (internal vaginal) examination to women and people with suspected endometriosis to identify abdominal masses and pelvic signs (e.g., reduced organ mobility and enlargement, tender nodularity in the posterior vaginal fornix, and visible vaginal endometriotic lesions).
If a pelvic examination is declined or unsuitable, offer an abdominal examination to exclude abdominal masses.
A normal physical examination does not exclude endometriosis.
Carry out additional investigations (e.g., ultrasound) and referral (if necessary, see below) in parallel with each other, and in conjunction with initial pharmacological treatment (see Key NICE recommendations on management).
Offer a transvaginal ultrasound scan (organised by the person’s general practice) to all women or people with suspected endometriosis, even if physical examination is normal, to:
Identify ovarian endometriomas and deep endometriosis (including that involving the bowel, bladder or ureter)
Identify or rule out other pathology which may be causing symptoms
Guide management options and enable referral to an appropriate service, depending on the ultrasound findings.
Consider a transabdominal pelvic ultrasound if transvaginal ultrasound is declined or unsuitable.
Normal ultrasound does not exclude endometriosis. Recognise that referral may still be necessary even with a normal scan.
Refer women or people with symptoms of (or confirmed) endometriosis to a gynaecology service for further investigation and management if they have:
Symptoms of endometriosis which have a detrimental impact on daily activities,or
Persistent or recurrent symptoms of endometriosis,or
Pelvic signs of endometriosis (but deep endometriosis is not suspected).
Refer women or people to a specialist endometriosis service if they have suspected or confirmed:
Endometrioma,or
Deep endometriosis (including that involving the bowel, bladder or ureter),or
Endometriosis outside the pelvic cavity.
Refer young women or people under 18 years with suspected or confirmed endometriosis to a paediatric and adolescent gynaecology service or specialist endometriosis service for further investigation and management.
Specialist transvaginal ultrasound scan or pelvic MRI (planned and interpreted by a professional with specialist expertise in gynaecological imaging) should be considered to diagnose (and assess the extent of) deep endometriosis.
Do not use serum CA125 to diagnose endometriosis.
Definitive diagnosis can only be made by specialist laparoscopic visualisation of the pelvis.
Diagnostic laparoscopy should be considered for diagnosis of suspected endometriosis, even if imaging is normal.
During diagnostic laparoscopy, a biopsy of suspected endometriosis may be taken:
To confirm the diagnosis (though normal histology does not exclude endometriosis)
To exclude malignancy if an endometrioma is treated but not excised.
See further laparoscopy recommendations in Surgical management below.
Link para a orientação do NICE
Endometriosis: diagnosis and management (NG73) November 2024. https://www.nice.org.uk/guidance/ng73
Principais recomendações do NICE sobre tratamento
Please be aware that some of the following indications for medications may not be licensed by the manufacturer (i.e., the use of the medication is ‘off-label’). Refer to the full NICE guideline and your local drug formulary for further information when prescribing.
Offer endometriosis treatment according to the woman's symptoms, preferences and priorities, rather than the stage of the endometriosis.
Explain that available evidence does not support the use of traditional Chinese medicine or other Chinese herbal medicines or supplements in the treatment of endometriosis.
Women or people with endometriosis-related subfertility who wish to prioritise fertility should be managed by a multidisciplinary team with input from a fertility specialist. See the NICE guideline section Management if fertility is a priority for further information.
Management should include the recommended diagnostic fertility or preoperative tests, as well as other recommended fertility treatments (e.g., assisted reproduction) that are included in the NICE guideline Fertility problems: assessment and treatment (CG156).
Do not offer hormonal treatment (alone or in combination with surgery) to women or people with endometriosis who are trying to conceive, because it does not improve spontaneous pregnancy rates.
Initial pharmacological treatment for suspected or confirmed endometriosis
Consider a short trial (e.g., 3 months) of paracetamol or a non-steroidal anti-inflammatory drug alone or in combination, as first-line management for endometriosis-related pain.
If a trial does not provide adequate pain relief, consider referring for further assessment and offering other forms of pain management.
Offer hormonal treatment (e.g., combined oral contraceptive pill or a progestogen) to women or people with suspected, confirmed or recurrent endometriosis who are not trying to conceive.
Explain that it can reduce pain and has no permanent negative effect on subsequent fertility.
Neuromodulators and other neuropathic pain treatments may be considered to treat neuropathic pain, in line with the NICE guideline Neuropathic pain in adults: pharmacological management in non-specialist settings (CG173).
Refer to an appropriate gynaecology service for further investigation and management if initial treatment is not effective, not tolerated or is contraindicated.
Surgical management
Surgical management may be considered, depending on the woman’s symptoms, preferences and priorities with respect to pain and fertility.
Surgery for endometriosis is performed laparoscopically unless there are contraindications.
Surgical treatment may take place (with prior patient consent) during a diagnostic laparoscopy if any uncomplicated endometriosis is found.
If deep endometriosis is suspected, a specialist pelvic ultrasound or MRI should be considered before an operative laparoscopy.
Excision rather than ablation should be considered to treat endometriomas, taking into account the woman's desire for fertility and her ovarian reserve (e.g., if fertility is a priority, excision or ablation and drainage should be considered, as the latter may preserve ovarian reserve more than cystectomy).
If hysterectomy is indicated (e.g., the woman has adenomyosis or heavy menstrual bleeding that has not responded to other treatments), all visible endometriotic lesions should be excised at the time of the hysterectomy.
Hormonal treatment may be used alongside surgical management, except in women or people who are trying to conceive.
A 3-month treatment with gonadotrophin-releasing hormone agonists should be considered as an adjunct before surgery for deep endometriosis involving the bowel, bladder or ureter.
Post-operative hormonal treatment (e.g., combined oral contraceptive pill) should be considered after laparoscopic excision or ablation, to prolong the benefits of surgery and manage symptoms.
Monitoring
Women with confirmed endometriosis (particularly those who decline surgery) should be considered for outpatient follow-up if they have:
Deep endometriosis involving the bowel, bladder or ureter,or
1 or more endometrioma that is larger than 3 cm.
© NICE (2024). All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.
Link para a orientação do NICE
Endometriosis: diagnosis and management (NG73) November 2024. https://www.nice.org.uk/guidance/ng73
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