Post on 10-Mar-2020
Pelvic pain
Dr Julie Oliver
GPwSI gynaecology
Conflict of interests Trainer for Bayer Director Primary Care Womenrsquos health Forum
Acute pelvic pain
Clinical case - Sarah
bull Aged 21
bull On call triage screen
bull Lower abdo pains
bull Triage outcome to come in
What next
bull Pulse and BP fine
bull Abdo examination ndash mild discomfort over all the lower abdo
bull No masses
bull Temperature normal
bull Pregnancy test - positive
Management plan
Referral to early pregnancy unit
OR
Referral to on-call gynae
Outcome
Ectopic pregnancy
11 000 per year
1 in 80 pregnancies
Early recognition -gt Methotrexate
Confidential enquiry 2015
bull 8 deaths 2010-12 in early pregnancy
bull Numbers failing
bull Delay in recognition most common factor
Maternal death rates UK
Top tip 1
Always consider ECTOPIC pregnancy in a woman of
reproductive age
Pelvic pain
bull Emma 24
bull Heavy painful periods getting worse ndash over 6 months now
bull Painful sex
bull Emergency triage screen
bull EXAMINATION - normal
ENDOMETRIOSIS
bull TESTS
bull Bloods ndash FBC fibroid
bull Swabs - PID
bull Ultrasound ndash pick up ovarian cysts but not endometriosis lesions
bull Laparoscopy ndash symptoms alone poor predictor of finding endometriosis at laparoscopy
WHO WOULD REFER NOW
Endometriosis
bull Average of 75 years delay to diagnosis
bull 1 in 10 women
bull ENDOMETRIOSIS UK
Enometriosis cyst
Laparoscopy 13 to 12 are negative
Green top guidelines RCOG 41
Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3ndash6 months before having a diagnostic laparoscopy
Published 2012
Treatment to start
Ovarian suppression
1 Combined hormonal contraceptive pill 2 Desogestrel progesterone only pill 3 Depo proveraSayana Press 3 Mirena IUS Jaydess IUS
Others danazol or GnRH (not for us )
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Acute pelvic pain
Clinical case - Sarah
bull Aged 21
bull On call triage screen
bull Lower abdo pains
bull Triage outcome to come in
What next
bull Pulse and BP fine
bull Abdo examination ndash mild discomfort over all the lower abdo
bull No masses
bull Temperature normal
bull Pregnancy test - positive
Management plan
Referral to early pregnancy unit
OR
Referral to on-call gynae
Outcome
Ectopic pregnancy
11 000 per year
1 in 80 pregnancies
Early recognition -gt Methotrexate
Confidential enquiry 2015
bull 8 deaths 2010-12 in early pregnancy
bull Numbers failing
bull Delay in recognition most common factor
Maternal death rates UK
Top tip 1
Always consider ECTOPIC pregnancy in a woman of
reproductive age
Pelvic pain
bull Emma 24
bull Heavy painful periods getting worse ndash over 6 months now
bull Painful sex
bull Emergency triage screen
bull EXAMINATION - normal
ENDOMETRIOSIS
bull TESTS
bull Bloods ndash FBC fibroid
bull Swabs - PID
bull Ultrasound ndash pick up ovarian cysts but not endometriosis lesions
bull Laparoscopy ndash symptoms alone poor predictor of finding endometriosis at laparoscopy
WHO WOULD REFER NOW
Endometriosis
bull Average of 75 years delay to diagnosis
bull 1 in 10 women
bull ENDOMETRIOSIS UK
Enometriosis cyst
Laparoscopy 13 to 12 are negative
Green top guidelines RCOG 41
Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3ndash6 months before having a diagnostic laparoscopy
Published 2012
Treatment to start
Ovarian suppression
1 Combined hormonal contraceptive pill 2 Desogestrel progesterone only pill 3 Depo proveraSayana Press 3 Mirena IUS Jaydess IUS
Others danazol or GnRH (not for us )
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Clinical case - Sarah
bull Aged 21
bull On call triage screen
bull Lower abdo pains
bull Triage outcome to come in
What next
bull Pulse and BP fine
bull Abdo examination ndash mild discomfort over all the lower abdo
bull No masses
bull Temperature normal
bull Pregnancy test - positive
Management plan
Referral to early pregnancy unit
OR
Referral to on-call gynae
Outcome
Ectopic pregnancy
11 000 per year
1 in 80 pregnancies
Early recognition -gt Methotrexate
Confidential enquiry 2015
bull 8 deaths 2010-12 in early pregnancy
bull Numbers failing
bull Delay in recognition most common factor
Maternal death rates UK
Top tip 1
Always consider ECTOPIC pregnancy in a woman of
reproductive age
Pelvic pain
bull Emma 24
bull Heavy painful periods getting worse ndash over 6 months now
bull Painful sex
bull Emergency triage screen
bull EXAMINATION - normal
ENDOMETRIOSIS
bull TESTS
bull Bloods ndash FBC fibroid
bull Swabs - PID
bull Ultrasound ndash pick up ovarian cysts but not endometriosis lesions
bull Laparoscopy ndash symptoms alone poor predictor of finding endometriosis at laparoscopy
WHO WOULD REFER NOW
Endometriosis
bull Average of 75 years delay to diagnosis
bull 1 in 10 women
bull ENDOMETRIOSIS UK
Enometriosis cyst
Laparoscopy 13 to 12 are negative
Green top guidelines RCOG 41
Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3ndash6 months before having a diagnostic laparoscopy
Published 2012
Treatment to start
Ovarian suppression
1 Combined hormonal contraceptive pill 2 Desogestrel progesterone only pill 3 Depo proveraSayana Press 3 Mirena IUS Jaydess IUS
Others danazol or GnRH (not for us )
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
What next
bull Pulse and BP fine
bull Abdo examination ndash mild discomfort over all the lower abdo
bull No masses
bull Temperature normal
bull Pregnancy test - positive
Management plan
Referral to early pregnancy unit
OR
Referral to on-call gynae
Outcome
Ectopic pregnancy
11 000 per year
1 in 80 pregnancies
Early recognition -gt Methotrexate
Confidential enquiry 2015
bull 8 deaths 2010-12 in early pregnancy
bull Numbers failing
bull Delay in recognition most common factor
Maternal death rates UK
Top tip 1
Always consider ECTOPIC pregnancy in a woman of
reproductive age
Pelvic pain
bull Emma 24
bull Heavy painful periods getting worse ndash over 6 months now
bull Painful sex
bull Emergency triage screen
bull EXAMINATION - normal
ENDOMETRIOSIS
bull TESTS
bull Bloods ndash FBC fibroid
bull Swabs - PID
bull Ultrasound ndash pick up ovarian cysts but not endometriosis lesions
bull Laparoscopy ndash symptoms alone poor predictor of finding endometriosis at laparoscopy
WHO WOULD REFER NOW
Endometriosis
bull Average of 75 years delay to diagnosis
bull 1 in 10 women
bull ENDOMETRIOSIS UK
Enometriosis cyst
Laparoscopy 13 to 12 are negative
Green top guidelines RCOG 41
Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3ndash6 months before having a diagnostic laparoscopy
Published 2012
Treatment to start
Ovarian suppression
1 Combined hormonal contraceptive pill 2 Desogestrel progesterone only pill 3 Depo proveraSayana Press 3 Mirena IUS Jaydess IUS
Others danazol or GnRH (not for us )
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Management plan
Referral to early pregnancy unit
OR
Referral to on-call gynae
Outcome
Ectopic pregnancy
11 000 per year
1 in 80 pregnancies
Early recognition -gt Methotrexate
Confidential enquiry 2015
bull 8 deaths 2010-12 in early pregnancy
bull Numbers failing
bull Delay in recognition most common factor
Maternal death rates UK
Top tip 1
Always consider ECTOPIC pregnancy in a woman of
reproductive age
Pelvic pain
bull Emma 24
bull Heavy painful periods getting worse ndash over 6 months now
bull Painful sex
bull Emergency triage screen
bull EXAMINATION - normal
ENDOMETRIOSIS
bull TESTS
bull Bloods ndash FBC fibroid
bull Swabs - PID
bull Ultrasound ndash pick up ovarian cysts but not endometriosis lesions
bull Laparoscopy ndash symptoms alone poor predictor of finding endometriosis at laparoscopy
WHO WOULD REFER NOW
Endometriosis
bull Average of 75 years delay to diagnosis
bull 1 in 10 women
bull ENDOMETRIOSIS UK
Enometriosis cyst
Laparoscopy 13 to 12 are negative
Green top guidelines RCOG 41
Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3ndash6 months before having a diagnostic laparoscopy
Published 2012
Treatment to start
Ovarian suppression
1 Combined hormonal contraceptive pill 2 Desogestrel progesterone only pill 3 Depo proveraSayana Press 3 Mirena IUS Jaydess IUS
Others danazol or GnRH (not for us )
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Outcome
Ectopic pregnancy
11 000 per year
1 in 80 pregnancies
Early recognition -gt Methotrexate
Confidential enquiry 2015
bull 8 deaths 2010-12 in early pregnancy
bull Numbers failing
bull Delay in recognition most common factor
Maternal death rates UK
Top tip 1
Always consider ECTOPIC pregnancy in a woman of
reproductive age
Pelvic pain
bull Emma 24
bull Heavy painful periods getting worse ndash over 6 months now
bull Painful sex
bull Emergency triage screen
bull EXAMINATION - normal
ENDOMETRIOSIS
bull TESTS
bull Bloods ndash FBC fibroid
bull Swabs - PID
bull Ultrasound ndash pick up ovarian cysts but not endometriosis lesions
bull Laparoscopy ndash symptoms alone poor predictor of finding endometriosis at laparoscopy
WHO WOULD REFER NOW
Endometriosis
bull Average of 75 years delay to diagnosis
bull 1 in 10 women
bull ENDOMETRIOSIS UK
Enometriosis cyst
Laparoscopy 13 to 12 are negative
Green top guidelines RCOG 41
Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3ndash6 months before having a diagnostic laparoscopy
Published 2012
Treatment to start
Ovarian suppression
1 Combined hormonal contraceptive pill 2 Desogestrel progesterone only pill 3 Depo proveraSayana Press 3 Mirena IUS Jaydess IUS
Others danazol or GnRH (not for us )
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Ectopic pregnancy
11 000 per year
1 in 80 pregnancies
Early recognition -gt Methotrexate
Confidential enquiry 2015
bull 8 deaths 2010-12 in early pregnancy
bull Numbers failing
bull Delay in recognition most common factor
Maternal death rates UK
Top tip 1
Always consider ECTOPIC pregnancy in a woman of
reproductive age
Pelvic pain
bull Emma 24
bull Heavy painful periods getting worse ndash over 6 months now
bull Painful sex
bull Emergency triage screen
bull EXAMINATION - normal
ENDOMETRIOSIS
bull TESTS
bull Bloods ndash FBC fibroid
bull Swabs - PID
bull Ultrasound ndash pick up ovarian cysts but not endometriosis lesions
bull Laparoscopy ndash symptoms alone poor predictor of finding endometriosis at laparoscopy
WHO WOULD REFER NOW
Endometriosis
bull Average of 75 years delay to diagnosis
bull 1 in 10 women
bull ENDOMETRIOSIS UK
Enometriosis cyst
Laparoscopy 13 to 12 are negative
Green top guidelines RCOG 41
Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3ndash6 months before having a diagnostic laparoscopy
Published 2012
Treatment to start
Ovarian suppression
1 Combined hormonal contraceptive pill 2 Desogestrel progesterone only pill 3 Depo proveraSayana Press 3 Mirena IUS Jaydess IUS
Others danazol or GnRH (not for us )
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Confidential enquiry 2015
bull 8 deaths 2010-12 in early pregnancy
bull Numbers failing
bull Delay in recognition most common factor
Maternal death rates UK
Top tip 1
Always consider ECTOPIC pregnancy in a woman of
reproductive age
Pelvic pain
bull Emma 24
bull Heavy painful periods getting worse ndash over 6 months now
bull Painful sex
bull Emergency triage screen
bull EXAMINATION - normal
ENDOMETRIOSIS
bull TESTS
bull Bloods ndash FBC fibroid
bull Swabs - PID
bull Ultrasound ndash pick up ovarian cysts but not endometriosis lesions
bull Laparoscopy ndash symptoms alone poor predictor of finding endometriosis at laparoscopy
WHO WOULD REFER NOW
Endometriosis
bull Average of 75 years delay to diagnosis
bull 1 in 10 women
bull ENDOMETRIOSIS UK
Enometriosis cyst
Laparoscopy 13 to 12 are negative
Green top guidelines RCOG 41
Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3ndash6 months before having a diagnostic laparoscopy
Published 2012
Treatment to start
Ovarian suppression
1 Combined hormonal contraceptive pill 2 Desogestrel progesterone only pill 3 Depo proveraSayana Press 3 Mirena IUS Jaydess IUS
Others danazol or GnRH (not for us )
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Maternal death rates UK
Top tip 1
Always consider ECTOPIC pregnancy in a woman of
reproductive age
Pelvic pain
bull Emma 24
bull Heavy painful periods getting worse ndash over 6 months now
bull Painful sex
bull Emergency triage screen
bull EXAMINATION - normal
ENDOMETRIOSIS
bull TESTS
bull Bloods ndash FBC fibroid
bull Swabs - PID
bull Ultrasound ndash pick up ovarian cysts but not endometriosis lesions
bull Laparoscopy ndash symptoms alone poor predictor of finding endometriosis at laparoscopy
WHO WOULD REFER NOW
Endometriosis
bull Average of 75 years delay to diagnosis
bull 1 in 10 women
bull ENDOMETRIOSIS UK
Enometriosis cyst
Laparoscopy 13 to 12 are negative
Green top guidelines RCOG 41
Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3ndash6 months before having a diagnostic laparoscopy
Published 2012
Treatment to start
Ovarian suppression
1 Combined hormonal contraceptive pill 2 Desogestrel progesterone only pill 3 Depo proveraSayana Press 3 Mirena IUS Jaydess IUS
Others danazol or GnRH (not for us )
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Top tip 1
Always consider ECTOPIC pregnancy in a woman of
reproductive age
Pelvic pain
bull Emma 24
bull Heavy painful periods getting worse ndash over 6 months now
bull Painful sex
bull Emergency triage screen
bull EXAMINATION - normal
ENDOMETRIOSIS
bull TESTS
bull Bloods ndash FBC fibroid
bull Swabs - PID
bull Ultrasound ndash pick up ovarian cysts but not endometriosis lesions
bull Laparoscopy ndash symptoms alone poor predictor of finding endometriosis at laparoscopy
WHO WOULD REFER NOW
Endometriosis
bull Average of 75 years delay to diagnosis
bull 1 in 10 women
bull ENDOMETRIOSIS UK
Enometriosis cyst
Laparoscopy 13 to 12 are negative
Green top guidelines RCOG 41
Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3ndash6 months before having a diagnostic laparoscopy
Published 2012
Treatment to start
Ovarian suppression
1 Combined hormonal contraceptive pill 2 Desogestrel progesterone only pill 3 Depo proveraSayana Press 3 Mirena IUS Jaydess IUS
Others danazol or GnRH (not for us )
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Pelvic pain
bull Emma 24
bull Heavy painful periods getting worse ndash over 6 months now
bull Painful sex
bull Emergency triage screen
bull EXAMINATION - normal
ENDOMETRIOSIS
bull TESTS
bull Bloods ndash FBC fibroid
bull Swabs - PID
bull Ultrasound ndash pick up ovarian cysts but not endometriosis lesions
bull Laparoscopy ndash symptoms alone poor predictor of finding endometriosis at laparoscopy
WHO WOULD REFER NOW
Endometriosis
bull Average of 75 years delay to diagnosis
bull 1 in 10 women
bull ENDOMETRIOSIS UK
Enometriosis cyst
Laparoscopy 13 to 12 are negative
Green top guidelines RCOG 41
Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3ndash6 months before having a diagnostic laparoscopy
Published 2012
Treatment to start
Ovarian suppression
1 Combined hormonal contraceptive pill 2 Desogestrel progesterone only pill 3 Depo proveraSayana Press 3 Mirena IUS Jaydess IUS
Others danazol or GnRH (not for us )
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
ENDOMETRIOSIS
bull TESTS
bull Bloods ndash FBC fibroid
bull Swabs - PID
bull Ultrasound ndash pick up ovarian cysts but not endometriosis lesions
bull Laparoscopy ndash symptoms alone poor predictor of finding endometriosis at laparoscopy
WHO WOULD REFER NOW
Endometriosis
bull Average of 75 years delay to diagnosis
bull 1 in 10 women
bull ENDOMETRIOSIS UK
Enometriosis cyst
Laparoscopy 13 to 12 are negative
Green top guidelines RCOG 41
Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3ndash6 months before having a diagnostic laparoscopy
Published 2012
Treatment to start
Ovarian suppression
1 Combined hormonal contraceptive pill 2 Desogestrel progesterone only pill 3 Depo proveraSayana Press 3 Mirena IUS Jaydess IUS
Others danazol or GnRH (not for us )
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
WHO WOULD REFER NOW
Endometriosis
bull Average of 75 years delay to diagnosis
bull 1 in 10 women
bull ENDOMETRIOSIS UK
Enometriosis cyst
Laparoscopy 13 to 12 are negative
Green top guidelines RCOG 41
Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3ndash6 months before having a diagnostic laparoscopy
Published 2012
Treatment to start
Ovarian suppression
1 Combined hormonal contraceptive pill 2 Desogestrel progesterone only pill 3 Depo proveraSayana Press 3 Mirena IUS Jaydess IUS
Others danazol or GnRH (not for us )
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Endometriosis
bull Average of 75 years delay to diagnosis
bull 1 in 10 women
bull ENDOMETRIOSIS UK
Enometriosis cyst
Laparoscopy 13 to 12 are negative
Green top guidelines RCOG 41
Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3ndash6 months before having a diagnostic laparoscopy
Published 2012
Treatment to start
Ovarian suppression
1 Combined hormonal contraceptive pill 2 Desogestrel progesterone only pill 3 Depo proveraSayana Press 3 Mirena IUS Jaydess IUS
Others danazol or GnRH (not for us )
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Enometriosis cyst
Laparoscopy 13 to 12 are negative
Green top guidelines RCOG 41
Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3ndash6 months before having a diagnostic laparoscopy
Published 2012
Treatment to start
Ovarian suppression
1 Combined hormonal contraceptive pill 2 Desogestrel progesterone only pill 3 Depo proveraSayana Press 3 Mirena IUS Jaydess IUS
Others danazol or GnRH (not for us )
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Laparoscopy 13 to 12 are negative
Green top guidelines RCOG 41
Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3ndash6 months before having a diagnostic laparoscopy
Published 2012
Treatment to start
Ovarian suppression
1 Combined hormonal contraceptive pill 2 Desogestrel progesterone only pill 3 Depo proveraSayana Press 3 Mirena IUS Jaydess IUS
Others danazol or GnRH (not for us )
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Green top guidelines RCOG 41
Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of 3ndash6 months before having a diagnostic laparoscopy
Published 2012
Treatment to start
Ovarian suppression
1 Combined hormonal contraceptive pill 2 Desogestrel progesterone only pill 3 Depo proveraSayana Press 3 Mirena IUS Jaydess IUS
Others danazol or GnRH (not for us )
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Treatment to start
Ovarian suppression
1 Combined hormonal contraceptive pill 2 Desogestrel progesterone only pill 3 Depo proveraSayana Press 3 Mirena IUS Jaydess IUS
Others danazol or GnRH (not for us )
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Combined Hormonal Pill
1 ndash As prescribed 2- Extended regime
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Evidence for CHC
Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis a placebo-controlled double-blind randomized trial
Harada T1 Momoeda M Taketani Y Hoshiai H Terakawa N
1 Study published 2008 100 Women ndash placebo vs CHC (loestrin ) Pain scored after 4 cycles Treatment group significantly less pain BUT All women included had radiological evidence of
endometriosis
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Progesterone only pill
Stops ovulation 97 of cycles NB norgeston noriday micronor donrsquot
Progestagens and anti-progestagens for pain associated with endometriosis Prentice A1 Deary AJ Bland E
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Evidence to support POP
Reduced pelvic pain in women with endometriosis efficacy of long-term dienogest treatment
Petraglia F1 Hornung D Seitz C Faustmann T Gerlinger C Luisi S Lazzeri L Strowitzki T
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Depo proveraSayana press
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
LNG- IUS
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
LNG- IUS
Prospective observational study
34 recruited
29 complete
Significant reduction in pain and menstrual disorders at 6 months
The evaluation of the effectiveness of an intrauterine-administered
progestogen (levonorgestrel) in the symptomatic treatment of endometriosis and in the staging of the disease
Lockhat FB1 Emembolu JO Konje JC
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Top tip 2
Suspect endometriosis early
Despite limited good evidence offer hormonal contraception early to help
with pain
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Pelvic pain in gt50s New Symptoms suggestive of IBS in gt50s
THINK OVARIAN CANCER
bull PAIN
bull BLOATING
bull FEELING FULL UP QUICKLY
bull PASSING WATER MORE FREQUENTLY
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
What test
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
What test next
URGENT
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Where to refer to
Two week rule
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Top tip 3
THINK OVARIAN CANCER IF OVER 50 WITH PELVIC PAIN
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Questions
How often is a pregnancy ectopic
1 in 10
1 in 40
1 in 80
Laparoscopy is recommended early in investigation for pelvic pain Truefalse
In suspected endometriosis referral to gynaecology early is recommended to start GnRH analgoues Truefalse
Questions
bull Julieoliverdurham gynaecouk
Questions
bull Julieoliverdurham gynaecouk