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  • Journal of Obstetrics and Gynaecology CanadaThe offi cial voice of reproductive health care in Canada

    Le porte-parole offi ciel des soins gnsiques au CanadaJournal dobsttrique et gyncologie du Canada



    care in Canada

    siques au Canadogi

    Publications mailing agreement #40026233 Return undeliverable Canadian copies and change of address notifi cations to SOGC Subscriptions Services, 780 Echo Dr. Ottawa, Ontario K1S 5R7.

    Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S1

    Chapter 1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . S4

    Chapter 2: Pain Management . . . . . . . . . . . . . . . . . . . . . S6

    Chapter 3: Medical Management of Pain Associated With Endometriosis . . . . . . . . S9

    Chapter 4: Surgical Managementof Endometriosis . . . . . . . . . . . . . . . . . . . . .S15

    Chapter 5: Surgical Management of Infertility Associated With Endometriosis . . . . . . .S19

    Chapter 6: Medical Treatment of Infertility Related to Endometriosis . . . . . . . . . . . .S21

    Chapter 7: Endometriosis in Adolescents . . . . . . . .S23

    Chapter 8: Endometriosis and Cancer . . . . . . . . . . . .S26

    Volume 32, Number 7 volume 32, numro 7 July juillet 2010 Supplement 2 supplment 2

    Endometriosis:Diagnosis and Management

    Endometriosis:Diagnosis and Management

  • Editor-in-Chief / Rdacteur en chef Timothy Rowe

    CPL Editor / Rdactrice PPPVyta Senikas

    Translator / TraducteurMartin Pothier

    Assistant Editor / Rdactrice adjointeJane Fairbanks

    Editorial Assistant / Adjointe la rdactionDaphne Sams

    Editorial Office / Bureau de la rdactionJournal of Obstetrics and Gynaecology Canada Room D 405AWomen's Health Centre Building4500 Oak StreetVancouver BC V6H 3N1editor@sogc.comTel: (604) 875-2424 ext. 5668Fax: (604) 875-2590

    The Journal of Obstetrics andGynaecology Canada (JOGC) is owned by the Society of Obstetricians andGynaecologists of Canada (SOGC),published by the Canadian Psychiatric Association (CPA), and printed by DollcoPrinting, Ottawa, ON.

    Le Journal dobsttrique et gyncologie duCanada (JOGC), qui relve de la Socitdes obsttriciens et gyncologues duCanada (SOGC), est publi parlAssociation des psychiatres du Canada(APC), et imprim par Dollco Printing,Ottawa (Ontario).

    Publications Mail Agreement no.40026233. Return undeliverable Canadiancopies and change of address notices toSOGC, JOGC Subscription Service,780 Echo Dr., Ottawa ON K1S 5R7. USPS #021-912. USPS periodical postage paid at Champlain, NY, and additionallocations. Return other undeliverablecopies to International Media Services, 100 Walnut St., #3, PO Box 1518,Champlain NY 12919-1518.

    Numro de convention poste-publications40026233. Retourner toutes les copiescanadiennes non livres et les avis dechangement dadresse la SOGC, Service de labonnement au JOGC, 780, promenade Echo, Ottawa (Ontario), K1S 5R7. Numro USPS 021-912. Fraispostaux USPS au tarif des priodiquespays Champlain (NY) et autres bureaux de poste. Retourner les autres copies nonlivres International Media Services, 100 Walnut St., #3, PO Box 1518,Champlain (NY) 12919-1518.

    ISSN 1701-2163


    Endometriosis: Diagnosis and ManagementAbstract

    Objective: To improve the understanding of endometriosis and to

    provide evidence-based guidelines for the diagnosis and

    management of endometriosis.

    Outcomes: Outcomes evaluated include the impact of the medical

    and surgical management of endometriosis on womens

    experience of morbidity and infertility.

    Methods: Members of the guideline committee were selected on the

    basis of individual expertise to represent a range of practical and

    academic experience in terms of both location in Canada and type

    of practice, as well as subspecialty expertise along with general

    gynaecology background. The committee reviewed all available

    evidence in the English and French medical literature and

    available data from a survey of Canadian women.

    Recommendations were established as consensus statements.

    The final document was reviewed and approved by the Executive

    and Council of the SOGC.

    Results: This document provides a summary of up-to-date evidence

    regarding diagnosis, investigations, and medical and surgical

    management of endometriosis. The resulting recommendations

    may be adapted by individual health care workers when serving

    women with this condition.

    Conclusions: Endometriosis is a common and sometimes

    debilitating condition for women of reproductive age. A

    multidisciplinary approach involving a combination of lifestyle

    modifications, medications, and allied health services should be

    used to limit the impact of this condition on activities of daily living

    and fertility. In some circumstances surgery is required to confirm

    the diagnosis and provide therapy to achieve the desired goal of

    pain relief or improved fecundity. Women who find an acceptable

    management strategy for this condition may have an improved

    quality of life or attain their goal of successful pregnancy.

    Evidence: Medline and Cochrane databases were searched for

    articles in English and French on subjects related to

    endometriosis, pelvic pain, and infertility from January 1999 to

    October 2009 in order to prepare a Canadian consensus guideline

    on the management of endometriosis.

    Values: The quality of evidence was rated with use of the criteria

    described by the Canadian Task Force on Preventive Health Care.

    Recommendations for practice were ranked according to the

    method described by the Task Force. See Table 1.

    Benefits, harms, and costs: Implementation of the guideline

    recommendations will improve the care of women with pain and

    infertility associated with endometriosis.



    This Clinical Practice Guideline has been reviewed by the ClinicalPractice Gynaecology Committee and reviewed and approved bythe Executive and Council of the Society of Obstetricians andGynaecologists of Canada.


    Nicholas Leyland, MD, Toronto ON

    Robert Casper, MD, Toronto ON

    Philippe Laberge, MD, Quebec QC

    Sukhbir S. Singh, MD, Ottawa ON


    Lisa Allen, MD, Toronto ON

    Kristina Arendas, MD, Ottawa ON


    Nicholas Leyland, MD (Chair), Toronto ON

    Catherine Allaire, MD, Vancouver BC

    Alaa Awadalla, MD, Winnipeg MB

    Carolyn Best, MD, Hamilton ON

    Elizabeth Contestabile, RN, Ottawa ON

    Sheila Dunn, MD, Toronto ON

    Mark Heywood, MD, Vancouver BC

    Nathalie Leroux, MD, Montreal QC

    Frank Potestio, MD, Thunder Bay ON

    David Allan Rittenberg, MD, Halifax NS

    Sukhbir S. Singh, MD, Ottawa ON

    Rene Soucy, MD, Chandler QC

    Wendy Lynn Wolfman, MD, Toronto ON

    Vyta Senikas, MD, Ottawa, ON

    Disclosure statements have been received from all members ofthe committee.

    The literature searches and bibliographic support for this guideline were undertaken by Becky Skidmore, Medical Research Analyst,Society of Obstetricians and Gynaecologists of Canada.

    No. 244, July 2010

    This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The informationshould not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictateamendments to these opinions. They should be well documented if modified at the local level. None of these contents may bereproduced in any form without prior written permission of the SOGC.

    Key Words: Endometriosis, endometrioma, pelvic pain, infertility,laparoscopy

  • Summary Statements and Recommendations

    Chap ter 1: Intro duc tion

    Sum mary State ments

    1. Endometriosis is com mon, affect ing 5% to 10% of the femalepop u la tion, and the sig nif i cance of the dis ease depends on theclin i cal pre sen ta tion. (II-3)

    2. The cel lu lar and molec u lar etiologic the o ries of endometriosis asan inflam ma tory and estro gen-depend ent dis or der have improvedour under stand ing. (III)

    Chap ter 2: Pain Man age ment

    Sum mary State ments

    1. Symp toms may vary; how ever, cer tain hall mark symp toms may be more likely to sug gest endometriosis. The cli ni cian should beaware of atyp i cal pre sen ta tions. (I)

    2. Endometriosis can be a chronic, relaps ing dis or der, which mayneces si tate a long-term fol low-up. (I)

    3. When deeply infil trat ing endometriosis is sus pected, a pel vicexam i na tion, includ ing rectovaginal exam i na tion, is essen tial. (III)

    Rec om men da tions

    1. Inves ti ga tion of sus pected endometriosis should include his tory,phys i cal, and imag ing assess ments. (III-A)

    2. Rou tine CA-125 test ing as part of the diag nos tic inves ti ga tion ofendometriosis should not be per formed. (II-2D)

    Chapter 3: Medical Management of Pain AssociatedWith Endometriosis

    Rec om men da tions

    1. Com bined hor monal con tra cep tives, ide ally admin is teredcon tin u ously, should be con sid ered as first-line agents. (I-A)

    2. Admin is tra tion of progestin aloneorally, intra mus cu larly, orsub cu ta ne ouslymay also be con sid ered as first-line ther apy.(I-A)

    3. A GnRH ago nist with HT addback, or the LNG-IUS, should becon sid ered a sec ond-line ther a peu tic option. (I-A)

    4. A GnRH ago nist should be com bined with HT addback ther apyfrom com mence ment