Endometriosis

Rapid response to BMJ article by Engemise et al 26th June 2010
BMJ.com

Endometriosis – the missed disease

Engemise lists the classic symptoms of endometriosis, but doesn’t
describe dyschezia. This excruciating pain up the rectum, worst pre-
menstrually and during menstruation is classic of deep endometriosis in
the rectovaginal septum and should prompt the GP to refer the woman for a
Gynaecological opinion.

There is considerable delay between presentation to the GP and
diagnosis. The 7,025 women with endometriosis who took part in the survey
commissioned by the All Party Parliamentary Group for Endometriosis and
presented at the 9th World Congress in Maastricht 15th September 2005,
reported that they had waited three years before consulting with their
doctor in the first place. It then took an average of eight years from
first presentation to their GP/primary and diagnosis. Less than 50% felt
that their GP took them seriously when they first presented with symptoms
and 65% were told they had another condition prior to a correct diagnosis.

This delay may be due to the fact that the predictive value of any
symptom(s) remain uncertain and symptoms of endometriosis overlap with
normality such that dysmenorrhoea requiring simple analgesia or the
occasional “ouch” during sexual intercourse is probably normal; hence,
symptoms can be overlooked both by the woman and her General Practitioner.

It is estimated that four out of five women with endometriosis have had
time off work with pain. If these women were assumed to have a diagnosis
of endometriosis, this would make a considerable impact in reducing the
time to diagnosis of this missed disease. It is also worth noting that the
Gonadotrophin releasing hormone agonists are polypeptides and must be
administered either as a nasal spray or as an injection rather than a pill
as mentioned in the article. The combined oral contraceptive pill has
been shown to be as effective as the GnRH agonists for symptom control and
offers the possibility of long-term treatment in those women who don’t
want to conceive. This could be started by the GP and women referred to a
Gynaecologist if symptoms persisted. An alternative would be one of the
long acting reversible contraceptives such as depo-provera or the Mirena
Intrauterine System.

Alternative causes of pain could be excluded by basic investigations
arranged by the GP; pelvic ultrasound scan to identify an endometrioma,
testing for Chlamydia and empirical treatment for irritable bowel syndrome
and/or constipation. Referral to a gynaecologist would be appropriate if
the scan was abnormal, if the woman still had significant pain despite
treatment or was trying to get pregnant.

Thank you to the Authors and to Julia Harvey for highlighting this
missed disease.

Authors

Caroline Overton MBBS MD FRCOG FHEA

Former chair and medical advisor for Endometriosis UK

Consultant Gynaecologist & subspecialist University Hospitals Bristol

Claire Park MBBS MRCOG

Clinical Teaching Fellow in Obstetrics and Gynaecology

St Michaels Hospital

Vercellini P, Trespidi L, Colombo A, Vendola N, Marchini M,
Crosignani PG. A gonadotropin-releasing hormone agonist versus a low-dose
oral contraceptive for pelvic pain associated with endometriosis.
Fertil.Steril. 1993; 60:75-79.

Davis LJ, Kennedy SS, Moore J, Prentice A. Oral contraceptives for
pain associated with endometriosis. Cochrane Database of Systematic
Reviews 2007, Issue 3. Art. No.: CD001019. DOI:
10.1002/14651858.CD001019.pub2

www.endometriosis-uk.org
Endometriosis UK supports women living with endometriosis.

www.rcog.org.uk
Royal College of Obstetricians & Gynaecologists October 2006.
Endometriosis, investigation and management. Green-top guideline number
24.

Royal College of Obstetricians & Gynaecologists November 2007.
Patient information. Endometriosis: what you need to know.

Competing interests:
None declared