Managing endometriosis in primary care

Endometriosis is a chronic gynaecologic condition affecting up to one in every 10 women. KK Women’s and Children’s Hospital (KKH) in Singapore treats approximately 1,200 women with endometriosis-related problems every year. Audrey Abella speaks with Dr Wei-Wei Wee-Stekly, consultant at the Minimally Invasive Surgery Unit at KKH, on how this condition can be appropriately addressed in the primary care setting.

Endometriosis is characterized by the proliferation of cells from the uterine lining or endometrium to areas outside the uterine cavity (ie, ovaries, fallopian tubes, pelvis, or lower abdominal cavity). The uterine lining responds to menstrual hormones and causes ‘menstruation’ outside the womb, leading to inflammation, tissue damage, and scar formation (adhesions) over time. Consequently, this could lead to debilitating pain as well as infertility.

Endometriosis commonly affects the ovaries and could eventually give rise to ovarian cysts or endometrioma. It can also be found behind or within the womb, which could cause pelvic pain.

Approximately 30 percent of women complaining of severe menstrual pain are found to be suffering from endometriosis. However, the condition is often underdiagnosed as it may also be present in women with symptoms unrelated to periods or those who experience minimal discomfort. Most women suffer from very severe pain that could significantly impact their daily activities.

Diagnosing endometriosis

Key signs and symptoms that general practitioners (GPs) should look out for to facilitate an early and accurate diagnosis of endometriosis are as follows:

1.    Endometriotic spots that may be seen and/or felt occasionally on pelvic examination.

2.    Heavy or irregular menstruation.

3.    Pelvic mass from large ovarian cysts/endometrioma.

4.    Enlarged womb (adenomyosis) from infiltrative endometriosis.

5.    Chronic pelvic pain.

6.    Pain during menstruation.

7.    Pain during sexual activity.

8.    Bowel-related symptoms during menstruation (eg, diarrhoea, constipation, painful bowel movements).

9.    Urinary-related symptoms during menstruation (eg, painful urination, bloody urination).

10.  Subfertility.

Although pelvic ultrasound scans and blood tests may support the diagnosis, a surgical approach may be warranted for a more conclusive diagnosis. Diagnostic laparoscopy or keyhole surgery performed under general anaesthesia remains the gold standard for diagnosing endometriosis. Laparoscopy provides a detailed and magnified view inside the pelvis to ascertain the location, extent, and size of the endometriosis. Surgical removal of the endometriosis may be undertaken at the same setting.

However, several factors that could lead to a missed diagnosis are patients’ lack of awareness (as they might not seek consult with a GP) and ‘silent’ or asymptomatic cases which occur in about 10 percent of women. Another challenge is the presence of symptoms that may overlap with other conditions (ie, irritable bowel syndrome, interstitial cystitis).

While chronic pelvic pain can be a symptom of endometriosis, not all cases of pain can be attributed to endometriosis. Other differential diagnoses must be considered should a patient present with pain. Patients should be referred for tertiary assessment (ie, KK Endometriosis Centre) once endometriosis is suspected for further investigation to confirm the diagnosis.

GPs may refer to guidelines from NICE (NG73, September 2017) and ESHRE (September 2013) for the diagnosis and management of endometriosis. Although challenging at times, putting the guidelines into practice coupled with clinical judgment are important to customize treatment accordingly.

Treating endometriosis

The primary goal of endometriosis treatment is to alleviate symptoms and improve quality of life. Treatment options may include the use of pain killers to help mitigate mild menstrual pain, or hormonal therapies (ie, oral contraceptive pills, progesterone drugs, the testosterone derivative danazol, or gonadotropin-releasing hormone analogues [menopause-inducing injection]) to reduce pain and correct irregular or heavy menstrual flow.

No one treatment suits all, hence the need to tailor treatment for each patient. For instance, some adverse events from different treatment approaches may be considered severe and intolerable by some patients. Treatment for endometriosis is usually long-term given its chronic nature. Endometriosis may also recur once treatment is stopped.

Asymptomatic cases of endometriosis may not require treatment. For symptomatic cases, the KKH care team would typically start with empirical treatment with analgesia, followed by medium- to long-term hormonal medications, before considering surgery. Individualized treatment is ideally carried out in a dedicated multidisciplinary endometriosis centre.

GPs may provide handouts on endometriosis to raise patient awareness. Patients may also be encouraged to participate in support groups to help them better cope with, and gain a better understanding of, their condition by interacting with other women who have had or are still experiencing endometriosis.

Conclusion

When a woman presents with conditions such as chronic pelvic pain, dysmenorrhoea, heavy menstruation or pain during sexual activity, these may signal the likelihood of endometriosis. Should endometriosis be suspected, GPs are recommended to refer the patient to a dedicated multidisciplinary endometriosis centre (ie, KK Endometriosis Centre) for further investigations to diagnose the condition and obtain the best individualized treatment.