1 / 72

ESHRE GUIDELINE for the diagnosis and management of endometriosis

ESHRE GUIDELINE for the diagnosis and management of endometriosis. Thomas M. D’Hooghe, M.D., Ph.D. ESHRE SIG Endometriosis and Endometrium Leuven (Belgium) Postgraduate Course “Endometrium” 3 december 2009. LEARNING OBJECTIVES. At the conclusion of this presentation,

carmichaelc
Download Presentation

ESHRE GUIDELINE for the diagnosis and management of endometriosis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. ESHRE GUIDELINE for the diagnosis and management ofendometriosis Thomas M. D’Hooghe, M.D., Ph.D. ESHRE SIG Endometriosis and Endometrium Leuven (Belgium) Postgraduate Course “Endometrium” 3 december 2009

  2. LEARNING OBJECTIVES At the conclusion of this presentation, participants should be able to: 1. Summarize the development, updating and level of evidence associated with clinical guidelines in general 2. Apply the ESHRE guidelines for clinical management of endometriosis in their own clinical practice 3. Explain why many clinical issues with respect to endometriosis management are still unresolved and require more and better research.

  3. Why guidelines? 55% of adults receive recommended care 45% receive treatment they do not need, or are not given treatment they do need Asch et al, NEJM 2006 "Hysterectomies are still performed too often, on too many patients, unnecessarily" Sir Liam Donaldson, Chief Medical Officer UK, 2006

  4. Guideline A principle put forward to set standards or determine a course of action. Advice – counsel – direction – help – instruction – teaching – intelligence – lead – steer – direct – educate – oversee The Collins Concise Dictionary of English Language, Glasgow: William Collins & Sons Co Ltd, 1988. http://guidelines.endometriosis.org

  5. Guidelines The methodology for development of high-quality guidelines requires that the recommendations should be evidence-based. Appleyard et al, BJOG 2006 http://guidelines.endometriosis.org

  6. Evidence • n. that which makes evident Evident • a. visible; clear to the vision; obvious http://guidelines.endometriosis.org

  7. What is evidenced-based medicine? • The practice of medicine based on the best available evidence • EBM should be rational and logical, involving the application of common sense • EBM is not solely the application of randomized controlled trials or meta-analyses • EBM ≠ RCT • EBM considers both benefits and risks http://guidelines.endometriosis.org

  8. Why evidence-based medicine and guidelines? • A desire to do no harm and what is best • Evidence-based is evidently best • A response to peer and other external pressures • Clinical governance • Risk management • A coping strategy for dealing with information overload in clinical medicine http://guidelines.endometriosis.org

  9. Evidence-based medicine • Evidence-based medicine provides an environment in which physicians and patients can critically and objectively appraise clinical practice • Creation of guidelines is the natural endpoint of evidence-based medicine • Evidence-based medicine has limitations which should be acknowledged http://guidelines.endometriosis.org

  10. Danish National Guidelines "cases of minimal and mild endometriosis should be referred to and treated centrally in each county" and"cases of moderate to severe endometriosis, patients with disseminated disease such as recto-vaginal endometriosis, retro-peritoneal endometriosis or endometriosis on the bowels should be referred to one of two country centres of excellence: Copenhagen County Hospital Services (the County Hospital in Glostrup) and Aarhus University Hospital (Skejby Hospital)". Sundhedsstyrelsen (National Board of Health) Denmark: Guidelines for specialist treatment, February 2002

  11. Guideline Development Group Gerard Dunselmann Maastricht University (NL) Chair 2005-2007 Working party Andrew Prentice University of Cambridge (UK) Chair 2007-2010 Working party Charles Chapron Clinique Universitaire Baudelocque (F) Working party Robert Greb Münster University Hospital (D) Working party Thomas D’Hooghe Leuven University Hospital (B) Working party Daniela Hornung UFK Lübeck (G) Working party Lone Hummelshoj European Endometriosis Alliance (DK) Working party Stephen Kennedy University of Oxford (UK) Working party Ariel Revel University of Jerusalem (IS) Working party Ertan Saridogan University College London (UK) Working party http://guidelines.endometriosis.org

  12. Methodology (I) • Working group convened • Review of existing evidence-based guidelines and systematic reviews • Three meetings to develop and refine guideline • Guideline available for comment on the ESHRE website for 3 months • Ratification by working group by unanimous or near-unanimous voting • Approval by the ESHRE Executive Committee • Published in Human Reproduction Oct 2005 http://guidelines.endometriosis.org

  13. Methodology (II) Annual update process • Systematic review of publications 1966-2007 • 1st half of year: updates and distribution to working group • June: working group convened: ratification by working group unanimous or near-unanimous voting • Guideline available for peer review on the ESHRE website for 2 months • http://guidelines.endometriosis.orgupdated each year in October (last time 2008) http://guidelines.endometriosis.org

  14. Annual Update Cycle

  15. Sources (I) • Cochrane Library and the Cochrane Register of Controlled Trials were searched for relevant RCTs, systematic reviews and meta-analyses. • MEDLINE and PUBMED search from 1966 – Feb 2007. In addition: • Clinical Evidence – the monthly, updated directory of evidence on the effects of clinical interventions, published by the BMJ Publishing Group (UK) http://guidelines.endometriosis.org

  16. Sources (II) • NICE Guideline on the assessment and treatment of people with fertility problems, produced by the National Institute for Clinical Evidence (UK) • Guideline on the diagnosis and treatment of endometriosis, produced by the Dutch Society of Obstetrics and Gynaecology (NL) • Consensus statement for the management of chronic pelvic pain and endometriosis, produced by a group of US gynecologists (US) • Green Top Guideline on the investigation and management of endometriosis, by the Royal College of Obstetricians & Gynaecologists (UK) http://guidelines.endometriosis.org

  17. Recommendation: hierarchy of evidence http://guidelines.endometriosis.org

  18. Recommendation:strength of evidence http://guidelines.endometriosis.org

  19. Localization and appearance • Pelvic organs and peritoneum • Minimal to severe (ASRM classification 1996, FS 1997) • Presentation: peritoneal, ovarian, deep • Peritoneal: typical/subtle (red, white, clear) • Ovarian endometriotic cyst/endometrioma • Deeply infiltrative endo (DIE): > 5 mm • Adhesions  frozen pelvis http://guidelines.endometriosis.org

  20. Symptoms • Variable presentation/often asymptomatic • Overlap with other conditions causing pain (IBS, PID, ..) • Delay between onset of symptoms and definitive diagnosis up to 12 years • Typical: severe dysmenorrhea, deep dyspareunia, CPP, cyclical pain associated with bowel or bladder http://guidelines.endometriosis.org

  21. Clinical signs C http://guidelines.endometriosis.org

  22. Diagnosis C http://guidelines.endometriosis.org

  23. Diagnosis - histology GPP http://guidelines.endometriosis.org

  24. Diagnosis - histology GPP GPP http://guidelines.endometriosis.org

  25. Investigations: ultrasound A http://guidelines.endometriosis.org

  26. At present, there is insufficient evidence to indicate that MRI is a useful test to diagnose or exclude endometriosis compared to laparoscopy. Investigations: MRI http://guidelines.endometriosis.org

  27. Investigations: blood tests A http://guidelines.endometriosis.org

  28. Investigations – disease extent GPP http://guidelines.endometriosis.org

  29. Assessment of ovarian cysts GPP http://guidelines.endometriosis.org

  30. Diagnosis - laparoscopy GPP GPP http://guidelines.endometriosis.org

  31. Diagnosis - laparoscopy C C http://guidelines.endometriosis.org

  32. PAIN – empirical w/o diagnosis GPP http://guidelines.endometriosis.org

  33. PAIN (confirmed disease) -NSAIDs A It is important to note that NSAIDs have significant side effects, including gastric ulceration and an anti-ovulatory effect when taken mid-cycle. Other analgesics may be effective but there is insufficient evidence to make recommendations. http://guidelines.endometriosis.org

  34. PAIN -hormonal Tx A There are pilot data suggesting that the aromatase inhibitor, letrozole, may be effective, though there are concerns about bone density loss (Ailawadi et al, 2004). http://guidelines.endometriosis.org

  35. PAIN– duration of GnRH-a Tx A A http://guidelines.endometriosis.org

  36. PAIN – hormonal Treatment The levonorgestrel intrauterine device (LNG IUS) may be effective in reducing endometriosis-associated pain (Vercellini et al, 1999) but there is insufficient evidence to make recommendations. Statement in publication 2005 - adapted in 2006 http://guidelines.endometriosis.org

  37. PAIN – hormonal treatment A A systematic review identified two RCTs and three observational studies, all involving small numbers and a heterogeneous group of patients (Varma R et al, 2005). Nevertheless the evidence suggests that the LNG IUS reduces endometriosis-associated pain (Vercellini et al, 1999; Petta et al, 2005) with symptom control maintained over three years (Lockhat et al, 2005; Lockhat et al, 2004). Statement in revised guidelines 2006 http://guidelines.endometriosis.org

  38. PAIN – HRT C http://guidelines.endometriosis.org

  39. PAIN – surgical treatment A http://guidelines.endometriosis.org

  40. PAIN – surgical treatment Pre-operative treatment A http://guidelines.endometriosis.org

  41. PAIN – surgical treatment Post-operative treatment A http://guidelines.endometriosis.org

  42. INFERTILITY – hormonal treatment A http://guidelines.endometriosis.org

  43. INFERTILITY – surgical treatment A http://guidelines.endometriosis.org

  44. INFERTILITY – surgical treatment B http://guidelines.endometriosis.org

  45. INFERTILITY – surgical treatment A http://guidelines.endometriosis.org

  46. INFERTILITY – surgical treatment Post-operative treatment A http://guidelines.endometriosis.org

  47. INFERTILITY – ART: IUI A http://guidelines.endometriosis.org

  48. INFERTILITY – ART: IVF B A The recommendation above is based on a systematic review but the working group noted that endometriosis does not adversely affect pregnancy rates in some large databases (e.g. SART and HFEA) http://guidelines.endometriosis.org

  49. INFERTILITY – ART: COH for IVF B http://guidelines.endometriosis.org

  50. INFERTILITY – ART: IVF and recurrence risk of endo B http://guidelines.endometriosis.org

More Related