The current guidelines for the diagnosis and management of endometriosis is discussed.

1. Evaluation and Management of Endometriosis
Tevfik Yoldemir MD BSc MA PhD
Marmara University, School of Medicine,
Department of Obstetrics and Gynecology, Istanbul, Turkey
Photo
(compulsory)

2. I have no financial relationships to disclose.

3. DOI 10.1007/s00404-012-2361-z
Age pattern

4. doi.10.2147/IJGM.S261139

5. doi.10.2147/IJGM.S261139

6. Doi:10.1016/j.jmig.2021.08.032
Terminology

7. Primary locations of endometriosis,
their prevalence in patients with endometriosis
doi: 10.1007/s13244-017-0591-0

8. DOI: 10.1097/AOG.0000000000002469
Symptoms of endometriosis

9. Suspect endometriosis in women (including young women aged 17 and under)
presenting with 1 or more of the following symptoms or signs:
• chronic pelvic pain
• period-related pain (dysmenorrhoea) affecting daily activities and quality of life
• deep pain during or after sexual intercourse
• period-related or cyclical gastrointestinal symptoms, in particular, painful bowel
movements
• period-related or cyclical urinary symptoms, in particular, blood in the urine or
pain passing urine
• infertility in association with 1 or more of the above
NICE guideline
Published: 6 September 2017
www.nice.org.uk/guidance/ng73

10. Consider referring young women (aged 17 and under) with suspected or
confirmed endometriosis to a paediatric and adolescent gynaecology
service, gynaecology service or specialist endometriosis service
(endometriosis centre), depending on local service provision.
NICE guideline
Published: 6 September 2017
www.nice.org.uk/guidance/ng73

12. Refer women to a specialist endometriosis service if they have suspected
or confirmed:
• deep endometriosis involving the bowel, bladder or ureter, or
• endometriosis outside the pelvic cavity
NICE guideline
Published: 6 September 2017
www.nice.org.uk/guidance/ng73

13. NICE guideline
Published: 6 September 2017
www.nice.org.uk/guidance/ng73
Specialist endometriosis services (endometriosis centres) should have access to:
• gynaecologists with expertise in diagnosing and managing endometriosis, including
advanced laparoscopic surgical skills
• a colorectal surgeon with an interest in endometriosis
• a urologist with an interest in endometriosis
• an endometriosis specialist nurse
• a multidisciplinary pain management service with expertise in pelvic pain
• a healthcare professional with specialist expertise in gynaecological imaging of
endometriosis
• advanced diagnostic facilities (for example, radiology and histopathology)
• fertility services.

14. Doi: 10.1111/1471-0528.14838
Recommendations for the diagnosis

16. Sonographic examination
clinical suspicion of deep infiltrating endometriosis
doi: 10.1002/uog.15955
doi: 10.1046/j.1469-0705.2000.00287.x.
doi:10.1002/uog.14806

17. How to perform
an ultrasound
to diagnose
endometriosis
doi: 10.1002/ajum.12093

18. Transvaginal ultrasonography with bowel preparation
Before undergoing transvaginal ultrasonography, all patients
carried out bowel preparation by taking an oral laxative on
the eve of the exam (5.0 mg of sodium picosulfate) and a
rectal enema (120 ml of sodium diphosphate) within an hour
before initiation of exam, to eliminate any fecal residue and
gases present in the rectosigmoid
After the transducer was introduced transvaginally, it was
maintained at an angle of 30–608, in the antero-posterior
axis, and the rectum (lower, mid and upper) was examined,
followed by the sigmoid (Figure) as far as it was possible to
go (normally 30–40 cm from the anal verge)
doi:10.1093/humrep/dep433

19. Saline contrast sonovaginography
• a purpose-designed hydraulic ring (Colpo-Pneumo Occluder, Cooper Surgical,
Berlin, Germany) that inflates with approximately 40 mL of
saline solution in order to prevent the escape of the 60–120 mL of saline that is
subsequently injected into the vagina using a Foley catheter.
• The solution creates an acoustic window between the transvaginal probe and the
surrounding structures of the vagina and exerts a
pressure that distends the vaginal walls, permitting more complete visualization
of the vaginal walls and fornix, uterosacral ligaments, pouch of Douglas and
rectovaginal septum
DOI: 10.1002/uog.11102

20. Rectal water contrast transvaginal ultrasound
• Once the transducer was placed in the vagina, a 6 mm flexible catheter was
inserted in rectal lumen with a distance of 15 cm to the anus through the anus.
• To facilitate of the catheter passage, a gel containing lidocaine was applied.
• A 50 mL syringe connected with the catheter and warm saline solution then was
injected to the rectum as well as the sigmoid with ultrasonic control.
• The saline solution amount for showing the rectosigmoid varied from 100 to 350
mL, based on the intestinal wall dispensability.
• One hundred millilitres saline solution was slowly and continuously instilled at
the procedure beginning, and the rest solution was instilled if requested by
ultrasound.
doi:10.1136/ bmjopen-2017-017216

21. Diagnostic performance of TVS vs MRI for
detection of DIE
doi: 10.1002/uog.18961

22. Detection of endometriotic lesions in specific sites
doi:10.1055/s-0040-1718740

23. Pain Management
doi:10.1186/s12905-021-01545-5

24. DOI: 10.1097/AOG.0000000000002469

25. DOI: 10.1097/AOG.0000000000002469

28. DOI: 10.1177/2053369114568440
Endometriosis Lesion- Atrophy

29. doi: 10.1016/j.fertnstert.2016.10.022
Estrogen-Progestins
Monophasic OC vs CPA
Monophasic OC vs NETA
DSG vs monophasic OC
Danazol vs high dose OC vs mid dose OC
Vaginal ring vs Transdermal patch
Mid dose monophasic OC vs Leuprolide
DMPA vs mid dose monophasic OC
DSG vs Vaginal ring
Low dose multiphasic vs LNG-IUD
DSG vs low dose monophasic OC
Low dose multiphasic OC vs Leuprolide
DNG vs Triptorelin
LNG-IUD vs Leuprolide
DMPA vs Leuprolide
DNG vs Buserelin
Letrozole+NETA vs NETA
Etonogestrel implant vs DMPA
DNG vs Leuprolide
LNG-IUD vs Leuprolide
LNG-IUD vs DMPA
LNG_IUD vs Goserelin
Elagolix vs DMPA
DNG vs Goserelin
DNG vs NETA
Progestins
doi: 10.1080/09513590.2018.1490404

30. Pain Management
doi:10.1186/s12905-021-01545-5

31. Doi:10.1016/j.jmig.2021.08.032
Interventions

34. Doi:10.1016/j.jmig.2021.08.032
Lesion Recurrence

35. Doi: 10.1016/j.fertnstert.2016.10.022
Endometrioma Recurrence
Cyst Excision followed by OC or Progestin vs Expectant

36. doi.:10.1016/j.ejogrb.2016.11.015
The age-related recurrence of endometrioma
after conservative surgery postoperative 6 months 3.75 mg of leuprolide acetate
and estradiol 1 mg or equivalent with progestogen,
followed by cyclic, low-dose, monophasic OCs

37. doi:10.1016/j.ejogrb.2016.11.015
The age-related recurrence of endometrioma
after conservative surgery

38. Hysterectomy is effective in treating women with severe pain associated with
endometriosis.
Longterm follow-up reported a reoperation-free rate at 2, 5, and 7 years of 96%,
92%, and 92% in women with hysterectomy bilateral oophorectomy, respectively,
and 96%, 87%, and 77% in women with hysterectomy alone, respectively.
The risk of reoperation is 2.44 times higher with conservation of the ovaries.
DOI: 10.1097/AOG.0000000000002469

40. Infertility Treatment
doi:10.1186/s12905-021-01545-5

41. Infertility Treatment
doi:10.1186/s12905-021-01545-5

45. doi:10.1016/j.jmig.2020.11.020

46. doi:10.1093/humupd/dmx011
Postmenopausal endometriosis recurrence

47. doi:10.1093/humupd/dmx011
Postmenopausal endometriosis recurrence

48. doi.10.1080/13697137.2021.1998434
Menopausal hormonal therapy in surgically menopausal women

49. doi.10.1080/13697137.2021.1998434

50. doi.10.1080/13697137.2021.1998434

52. doi.10.1007/s00261-019-02309-4
In patients with previously identified endometrioma on imaging who do not
undergo surgical excision,
The Society of Radiologists in Ultrasound recommends
a minimum of one pelvic ultrasound per year to monitor the increases in
lesion size or evidence of other worrisome changes over time since an
estimated 1% of endometriomas undergoes malignant degeneration.
Endometriosis in the postmenopausal female

53. doi.10.3390/diagnostics12051212
171 patients
Three Predictive Indexes to Discriminate Malignant
Ovarian Tumors from Benign Ovarian Endometrioma
Copenhagen Index
Risk of ovarian malignancy algorithm

54. The R2 predictive index - high AUC in the pre-menopausal cohort;
the ROMA and CPH indexes - high AUCs in post-menopausal cohort.
doi.10.3390/diagnostics12051212

55. doi:10.1111/jog.13466
Ovarian endometriosis vs Epithelial ovarian cancer
doi:10.1016/S0090-8258(03)00414-1

56. Detection of ovarian cancer- Artificial Intelligence
Analytical Validation of a Deep Neural Network Algorithm for the Detection of Ovarian
Cancer JCO Clin Cancer Inform 6:e2100192
Evaluation of a convolutional neural network for ovarian tumor differentiation based on
magnetic resonance imaging. Eur Radiol 2020;1–12
Evaluation of machine learning methods with Fourier Transform features for classifying
ovarian tumors based on ultrasound images. PLoS One 2019;14:e0219388.
Improved deep learning network based in combination with cost-sensitive learning for early
detection of ovarian cancer in color ultrasound detecting system. J Med Syst 2019;43:251
Deep learning provides a new computed tomography-based prognostic biomarker for
recurrence prediction in high-grade serous ovarian cancer. Radiother Oncol 2019;132:171–7
Application of artificial intelligence for preoperative diagnostic and prognostic prediction in
epithelial ovarian cancer based on blood biomarkers. Clin Cancer Res 2019; 25:3006–15

57. doi:10.3109/13697137.2015.1041905
Ovarian cancer risk

58. doi:10.1097/AOG.0000000000001684.
Breast cancer – Endometriosis

59. doi: 10.1093/humupd/dmaa045.

60. doi: 10.1093/humupd/dmaa045.

61. doi.10.1007/s00261-019-02309-4
In patients with previously identified deeply infiltrative endometriosis, there is
thought to be a similar elevated risk of malignancy; however, no guidelines are
currently available for follow-up imaging, and practice varies among providers.
Given the risk for malignant degeneration, one could consider an initial follow-up
MRI in 6 months, followed by individualized intervals depending on the results.
If minimal change is noted, one could consider repeat imaging in 2–3 years for
follow-up.
If there is evidence of change in size or features of the lesions present at 6 months,
continued close surveillance with repeat MRI in 6–12 months could be performed.
Endometriosis in the postmenopausal female

64. www.eshre.eu/guidelines

65. THANK YOU FOR YOUR ATTENTION
tevfik.yoldemir@marmara.edu.tr
profdr.tevfikyoldemir
yoldemirtevfik

66. CC chemokine receptor type 1 (CCR1) antagonist BAY 86-5047
Doi:10.1080/09513590.2022.2133105
Emerging drugs for
non-hormonal treatment

67. Emerging drugs for non-hormonal treatment
Animal studies
Doi:10.1080/09513590.2022.2133105

68. Artificial Intelligence - Biomarkers
Doi:10.1038/s41746-022-00638-1

69. Artificial Intelligence – Protein Spectra
Doi:10.1038/s41746-022-00638-1

70. Artificial Intelligence - Protein Spectra
Doi:10.1038/s41746-022-00638-1

71. Artificial Intelligence – Clinical Variables and Symptoms
Doi:10.1038/s41746-022-00638-1

72. Artificial Intelligence – Clinical Variables and Symptoms
Doi:10.1038/s41746-022-00638-1

73. Artificial Intelligence – Genetic Variables
Doi:10.1038/s41746-022-00638-1

74. Artificial Intelligence – Genetic Variables
Doi:10.1038/s41746-022-00638-1

75. Artificial Intelligence – Mixed Variables
Doi:10.1038/s41746-022-00638-1