Overview of endometriosis, signs and symptoms, treatment options and Prescribed Minimum Benefit status in South Africa.

1. #SpeakUpAboutEndometriosis
Endometriosis
(en-doe-me-tree-O-sis)
You can’t
see it, but
we know
how it
feels!
L.ZA.MKT.10.2018.2951

2. #SpeakUpAboutEndometriosis
Endometriosis affects women of all ages?
Age 15-19
1%
Age 20-24
3%
25-29
7%
Age 30-34
12%
Age 35-39
19%
Age 40-44
26%
Age 45-49
19%
Age 50-55
13%
References: 1. Eisenberg VH, et al. Epidemiology of endometriosis: a large population-based database study from a healthcare provider with 2 million members. BJOG
2018; 125:55-62. 2. Arruda MS, et al. Time elapsed from onset of symptoms to diagnosis of endometriosis. Hum Reprod 2003; 18(4):756-759. L.ZA.MKT.10.2018.2951
Age at endometriosis diagnosis
(6,146 women between 15 – 55 years of age)1
Although many young
patients may report
symptoms of
endometriosis before
the age of 20, very
few are diagnosed
with endometriosis at
a young age.2
Endometriosis may
often be diagnosed
following fertility
problems.1

3. #SpeakUpAboutEndometriosis
What is endometriosis?
The endothelial cells that
form the lining of the uterus
(womb) grow elsewhere in
the body to produce
endometrium-like tissue,
and develop into
endometriotic lesions or
nodules.1
These lesions lead to a chronic,
inflammatory reaction,
accompanied by pain and the
formation of scar tissue and
adhesions (fibrous band of scar
tissue attaching or fusing
structures together).1
During surgery,
endometriosis lesions are
often described as looking
like “cigarette burns” inside
the abdomen, although
there are many different
variations as to how an
endometriosis lesion may
appear.
The most commonly affected
areas are regions in the pelvic
cavity, including the ovaries,
peritoneum, pouch of Douglas
and uterosacral ligaments.
Endometriosis can also
interfere with functioning of
the bowel or bladder,
depending on the site of the
endometriotic lesions.1
Reference: 1. Mueck AO. Dienogest: an oral progestogen for the treatment of endometriosis. Expert Rev
Obstet Gynecol 2011; 6(1):5-15.
L.ZA.MKT.10.2018.2951

4. #SpeakUpAboutEndometriosis
What is an Endometrioma?
Endometriosis can be located on and even within an ovary, causing
an endometrioma, or a cyst of endometriosis.
An endometrioma is the formation of a cyst within the ovary with
out-of-place endometrial tissue lining.1
It is formed when a tiny patch of endometrial tissue bleeds,
becomes transplanted, and grows and enlarges inside the ovaries.1
As the blood builds up over months and years, it turns brown.1
Endometriomas of the ovary (also known as chocolate cysts of the
ovary) contain degraded blood products that appear like chocolate
syrup.1
Ovarian endometriomas are a common presentation of
endometriosis.1,2
References: 1. Fertilitypedia. Endometrioma. Available from: https://fertilitypedia.org/edu/diagnoses/endometrioma#. [Accessed date 20 September 2018].
2. Riviello C, et al. Regression of a large endometrioma after treatment with dienogest. J Fertil In Vitro IVF World Reprod Med Genet Stem Cell Biol. 2016; 4(1):1-2.
L.ZA.MKT.10.2018.2951

5. #SpeakUpAboutEndometriosis
What are adhesions?
Adhesions by definition are fibrous bands of scar tissue and the
most common symptom that adhesions can cause is pain.
Endometriosis adhesions are unique and are often described as a
sort of super glue. This is because they possess a certain “sticky”
component that allows them to fuse together tissues and
connect organs.
The organs that are inside the abdomen and pelvic cavity have a
very special characteristic in that they are slippery, shiny and are
constantly moving.
Adhesions that form between organs limit their movement and
function, pulling on nerves and in doing so cause pain.
These adhesions can spread onto the intestines and are thus the
leading cause of bowel obstruction, causing such symptoms as
small stool production, constipation, and nausea.
Remember, not all adhesions cause pain and not all pain is
caused by adhesions.
Reference: Seckin MD Endometriosis Center. Adhesions: Definitions, Symptoms & Surgery. Available from: https://www.drseckin.com/pelvic-adhesion-
surgery#overview. [Accessed 5 October 2018]. L.ZA.MKT.10.2018.2951

6. #SpeakUpAboutEndometriosis
Why do adhesions occur?
Most adhesions form in response to a tissue disturbance that triggers the body’s repairing
mechanism, due to the bodies need to maintain balance.
Adhesions secondary to endometriosis:Endometriosis adhesions, composed of out-of-
place endometrial tissue, inflammatory enzymes and old, pooled menstrual blood, can
form throughout the pelvic cavity. These adhesions can be a cause of concern as their
formation can increase a patient’s chances of not only experiencing the symptoms (painful
periods, heavy menstrual period, etc.) of the underlying disease, but they can also put the
patient at greater risk to adopt other disorders such as infertility and bowel dysfunction or
even obstruction.
Adhesions secondary to surgery: One of the most common causes of adhesions is previous
surgery. Surgery is not something the body is used to, so it is only natural that adhesions
may form. Keep in mind, surgery should only be performed with patient consent and as a
last resort, if other treatment options are not beneficial to the patient. The whole point of
conducting surgery is so that it will most benefit the patient and relieve their symptoms.
However, this does not mean that complications cannot arise and risks are not involved,
one of which is adhesion formation.
Reference: Seckin MD Endometriosis Center. Adhesions: Definitions, Symptoms & Surgery. Available from: https://www.drseckin.com/pelvic-adhesion-
surgery#overview. [Accessed 5 October 2018]. L.ZA.MKT.10.2018.2951

7. #SpeakUpAboutEndometriosis
What causes or puts one at risk for endometriosis?
Endometriosis was first described in 1860. Nevertheless, the causes
remain uncertain1 and at present there is no consensus on the cause/s
of endometriosis.2 There are several different ideas of how and why
endometriosis happens.3
There is consistent evidence that a family history of endometriosis is
more common in women with the disease. The first degree relatives
(e.g. mother, sister) of affected women are at 3-9-times higher risk of
developing the disease.3 So there may be genes that influence
endometriosis.
Early age (<11 years of age) at the first menstrual period, and long and
heavy menstrual periods (> 7 days) have also been associated
consistently with endometriosis. These menstrual characteristics
(together with never having given birth) result in increased exposure
to menstruation, and provide strong support for the reflux theory.3
References: 1. Giudice LC, Kao LC. Endometriosis. Lancet. 2004; 364:1789-1799. 2. Leyland N, et al. SOGC Clinical Practice Guideline. Endometriosis and Management. J
Obstet Gynecol Can 2010; 32 (7 Suppl 2): S1-S32. 3. Parazzini F, et al. Epidemiology of endometriosis and its comorbidities. Eur J Obstet Gynecol Reprod Biol 2017;
209: 3–7. L.ZA.MKT.10.2018.2951

8. #SpeakUpAboutEndometriosis
What is the Reflux Theory?
The theory behind retrograde or reflux menstruation is that menstrual
blood containing endometrial cells flows back through the fallopian
tubes and into the pelvic cavity instead of out of the body.
This area provides support for the intestines and also contains the
bladder and reproductive organs. These displaced endometrial cells
stick to the pelvic walls and surfaces of pelvic organs, where they grow
and continue to thicken and bleed over the course of each menstrual
cycle.2
This theory does not explain the observation that reflux menstruation
occurs in most women but the disease affects only 5% to 10% of the
female population.2
Menstrual reflux might be considered as the initiating factor in the
development of endometriosis. However, the implantation of
endometrial cells in the pelvis needs promoting factors, including
hormonal activity, impaired immunological response and
inflammation.3
This process may be more common in some women due to inherited
conditions or genes.3
References: 1. Giudice LC, Kao LC. Endometriosis. Lancet. 2004; 364:1789-1799. 2. Leyland N, et al. SOGC Clinical Practice Guideline. Endometriosis and Management.
J Obstet Gynecol Can 2010; 32 . 3. Parazzini F, et al. Epidemiology of endometriosis and its comorbidities. Eur J Obstet Gynecol Reprod Biol 2017; 209: 3–7.
L.ZA.MKT.10.2018.2951

9. #SpeakUpAboutEndometriosis
age at 1st
baby
age at
onset of
menstrual
cycle
Is the incidence of endometriosis increasing?
number of
children
/pregnancies
Shorter
duration of
breastfeeding
Reproductive patterns of many women today differ
greatly from those of previous generations.
increase in the overall number of ovulations
and periods a woman has within a
reproductive lifespan
As the total lifetime exposure to menstrual reflux
increases, endometriosis develops.
Reference: Vercellini P, et al. Post-operative endometriosis recurrence: a plea for prevention based on pathogenetic, epidemiological, and clinical
evidence. Reprod Biomed Online 2010; 21:259–265. L.ZA.MKT.10.2018.2951
In other words, from an endometriosis point of view, no ovulation and no periods should be
the normal female condition until they want to fall pregnant.
24.9 (1974) yrs
– 29.6 (2004)
2.7 (1964) –
1.3 (2004)
6.2 months
(2000)

10. #SpeakUpAboutEndometriosis
Modern-day women experience three times as
many periods as their predecessors
Graziottin A. The shorter, the better: A review of the evidence for a shorter contraceptive hormone-free interval, Euro J of Contracep & Reprod
Health Care 2016; 21(2): 93-105. L.ZA.MKT.10.2018.2951
Late
menarche
Early first
pregnancies
Long duration of
breastfeeding
Many
pregnancies
New
menstruations
Until ~ 1900
= 160 periods
Early
menarche
Numerous
menstruations
Short duration
of breastfeeding
Late first
pregnancies
Reduced number
of children
= 450 periods
Present

11. #SpeakUpAboutEndometriosis
Does the immune system play a role?
The immune system is believed to be involved in the
development of endometriosis and several studies have shown
an association between immunological-related/autoimmune-
mediated diseases and endometriosis.1
It's possible that a problem with the immune system may make
the body unable to recognize and destroy the endometrial
tissue that's growing outside the uterus.2
However, in general, published studies do not provide
information on the sequence of endometriosis and the various
associated immunological diseases.1
As such, it is not known whether immune dysfunction is a
cause or a consequence of endometriosis.1
References: 1. Parazzini F, et al. Epidemiology of endometriosis and its comorbidities. Eur J Obstet Gynecol Reprod Biol 2017; 209: 3–7. 2. Giudice LC, Kao
LC. Endometriosis. Lancet. 2004; 364:1789-1799. L.ZA.MKT.10.2018.2951

12. #SpeakUpAboutEndometriosis
What are the most common symptoms of endometriosis?
Symptoms vary but in particular, women experiencing the following symptoms have a high risk of
having endometriosis, especially if they experience more than one of these symptoms.
While it is recognised that the symptoms identified as being associated with endometriosis
are not entirely specific to the condition, there is good evidence to suggest that women
reporting multiple symptoms should seek medical advice to exclude or confirm a diagnosis of
endometriosis.
stomach and/or
pelvic pain
unrelated to the
menstrual cycle,
constipation, pain
on passing urine or
stools
menstrual-related
symptoms (pain
during menstrual
periods and heavy
or prolonged
menstrual
bleeding),
symptoms related to
sexual intercourse
(persistent or recurrent
genital pain that occurs
just before, during or
after intercourse and/or
bleeding from the vagina
after sexual intercourse),
ovarian cysts,
and subfertility
(difficulty falling
pregnant) or
infertility
Reference: Ballard K, et al. Can symptomatology help in the diagnosis of endometriosis? Findings from a national case– control study—Part 1. BJOG 2008;
115:1382–1391. L.ZA.MKT.10.2018.2951

13. #SpeakUpAboutEndometriosis
Diagnosis
Average of 7 primary care visits before specialist referral
Long Delay in Getting a Diagnosis for Endometriosis
Reference: Nnoaham KE, et al. Impact of endometriosis on quality of life and work productivity. Fertil Steril 2011; 96(2): 366–373. L.ZA.MKT.10.2018.2951

14. #SpeakUpAboutEndometriosis
Delays in the diagnosis of endometriosis are at
a patient and medical level
Frequent Misdiagnosis2
74% of women receive ≥1
false diagnoses1
References 1. Ballard K, et al. What’s the delay? A qualitative study of women’s experiences of reaching a diagnosis of endometriosis. Fertil Steril 2006; 86(5):
1296–1301. 2. Hudelist G, et al. Diagnostic delay for endometriosis in Austria and Germany: causes and possible consequences. Hum Reprod 2012;
27(12):34120-6. L.ZA.MKT.10.2018.2951
Normalisation of
symptoms1
Embarassment1
Fear of being seen
as unable to cope1
8%
12%
12%
14%
17%
17%
26%
35%
45%
Idiopathic sterility
Appendicitis
Pelvic Inflamatory Disease (PID)
Irritable bladder
Intolerances
Psychosexual complaints
Irritable colon
Bleeding disorder
Chronic Pelvic Pain Syndrome
Women wait 2.3 yrs. before
seeking medical attention1
Wait

15. #SpeakUpAboutEndometriosis
Why Speak Up About Endometriosis?
The importance of a diagnosis
Confirms the genuineness of the symptoms.1
Increases the potential for appropriate treatment
strategies;1
Treatment improves quality of life;
Brings relief through providing a language to talk about
symptoms;1
Allows patients to seek social support;1
Provides further relief that there is not a more sinister
problem, such as cancer.1
Provides legitimate reasons for absence from normal social
and work roles when necessary.1
It’s not all in
my head – it’s
got a name 2
References: Ballard K, et al. What’s the delay? A qualitative study of women's experiences of reaching a diagnosis of endometriosis. Fertil Steril. 2006 86(5):1296 – 1301
2. Young K, et al. Women’s experiences of endometriosis: a systematic review and synthesis of qualitative research. J Fam Plann Reprod Health Care 2014;0:1-10
L.ZA.MKT.10.2018.2951

16. #SpeakUpAboutEndometriosis
Endometriosis and Infertility
Endometriosis has been associated with infertility, however the mechanism by which it
affects fertility is still not fully understood.
25%–50% of women with infertility are diagnosed with endometriosis and 30–50% of
women with endometriosis have infertility.
Inflammatory effects resulting from the presence of endometriomas have been shown to
affect both “egg” (oocyte) production and ovulation in the affected ovary.
Sperm quality or function is also decreased and has been proposed to be from the
inflammatory/toxic affects of the peritoneal fluid and increased activated white blood cells
of the immune system.
In addition to the above-mentioned inflammatory effects of endometriosis there is increasing
evidence that endometriosis affects the actual lining of the uterus (womb) and causes
implantation failure, however the mechanism of signaling from the lesion to the uterus is
unknown.
Ultimately, the optimal method for treatment of endometriosis-associated infertility is an
individualized decision that should be made on patient-specific basis.
Many factors must be taken into account including but not limited to distorted pelvic
anatomy, patient’s ovarian reserve, partner semen analysis, age, presence of
endometriomas, and length of infertility.
Reference: Macer M, Taylor H. Endometriosis and Infertility: A review of the pathogenesis and treatment of endometriosis-associated infertility.
Obstet Gynecol Clin North Am. 2012; 39(4): 535–549. L.ZA.MKT.10.2018.2951

17. #SpeakUpAboutEndometriosis
Questionnaire: To Assist with diagnosis
L.ZA.MKT.10.2018.2951

18. #SpeakUpAboutEndometriosis
How is endometriosis diagnosed?
Although the gold standard for diagnosis
of endometriosis is direct visualization at
laparoscopy and histologic study,
diagnostic laparoscopy is not required
before treatment in all patients
presenting with pelvic pain.
The primary focus of investigation and
treatment of endometriosis should be
resolution of the symptoms the patient
is experiencing.
Reference: 1. Leyland N, et al. SOGC Clinical Practice Guideline. Endometriosis: Diagnosis and Management. J Obstet Gynecol Can 2010; 32
(7 Suppl 2): S1-S32. L.ZA.MKT.10.2018.2951

19. #SpeakUpAboutEndometriosis
Do you always need surgery to diagnose?
The use of diagnostic laparoscopy should be limited and laparoscopy should
generally be performed only if the surgeon is prepared to remove lesions if
endometriosis is discovered.
The decision to move to surgery in women with pain and suspected
endometriosis should be based on clinical evaluation, imaging, and effectiveness
of medical treatment.
The Canadian Endometriosis Guidelines, amongst others, recommend that
surgical management in women with endometriosis-related pain should be
reserved for those in whom medical treatment has failed.
In endometriosis treatment, all medical treatment options should be
administered for a minimum of 3 months, with evaluation of efficacy at the end
of the trial period.
Reference: 1. Leyland N, et al. SOGC Clinical Practice Guideline. Endometriosis: Diagnosis and Management. J Obstet Gynecol Can 2010; 32
(7 Suppl 2): S1-S32. L.ZA.MKT.10.2018.2951

20. #SpeakUpAboutEndometriosis
Is there a Cure for Endometriosis?
“Endometriosis is viewed best primarily
as a medical disease with surgical
back-up”
“Multiple surgical procedures should be
avoided whenever possible, because
surgery has inherent risks and also
might result in adhesions that can
cause pelvic pain”
References: The Practice Committee of the
American Society for Reproductive Medicine.
Treatment of pelvic pain associated with
endometriosis. Fertil Steril 2008; 90(Suppl 3): S260-
S269.
“… endometriosis is a chronic
and incurable disease in a
significant number of women.1
The treatments… can offer
(partial) relief of pain
symptoms, but symptoms
often recur after
discontinuation of therapy”2,3
References: 1. Leyland N, et al. SOGC Clinical Practice Guideline.
Endometriosis: Diagnosis and Management. J Obstet Gynecol
Can 2010; 32 (7 Suppl 2): S1-S32. 2. Dunselman G, et al. ESHRE
guideline: management of women with endometriosis. Human
Reproduction 2014; 29(3):400–412. 3. Johnson N, Hummelshoj L.
WES Consensus on current management of endometriosis.
Human Reproduction 2013; 28 (6): 1552–1568.
L.ZA.MKT.10.2018.2951

21. #SpeakUpAboutEndometriosis
The Goals of Endometriosis Management
Treat the symptoms
Improve quality of life1
If the symptom is pain, alleviate the pain1
If the symptom is infertility, assist fertility1
Reduce risk of disease progression
Preserve fertility
Prevent the progression to chronic pain
Acceptable side effect profile, suitable for long-term use
Keep surgeries to a minimum
Identify patients who will really benefit, and find the best time for surgery
Reduce the lesions1
Prevent disease recurrence- Importance of post-surgical maintenance
References: 1. Mueck AO. Dienogest: an oral progestogen for the treatment of endometriosis. Expert Rev Obstet Gynecol 2011; 6(1):5-15. 2. Leyland N, et al. SOGC Clinical
Practice Guideline. Endometriosis: Diagnosis and Management. J Obstet Gynecol Can 2010; 32 (7 Suppl 2): S1-S32. L.ZA.MKT.10.2018.2951

22. #SpeakUpAboutEndometriosis
What treatments are available?
There is no cure for endometriosis, but treatments are available for the symptoms and
problems it causes. Talk to your doctor about your treatment options.
Medical Treatments
Many clinicians support empirical medical treatment of
endometriosis either prior to or without laparoscopic confirmation
of endometriosis.2
Non-steroidal anti-inflammatories (NSAIDS) for pain management1
If the patient is not trying to get pregnant, hormonal treatment is
generally the first step. This may include:
Progestogens (hormones): Specifically designed to treat
endometriosis. They reduce or even stop menstrual bleeding
and ovulation and reduce or eliminate the pain.
Birth control pills: Extended-cycle (you have only a few periods
a year) or continuous cycle (you have no periods) birth control.
These hormonal birth control pills help stop bleeding and
reduce or eliminate pain.
Intrauterine device (IUD) to help reduce pain and bleeding.
The hormonal IUD protects against pregnancy for up to 5
years.
In endometriosis treatment, all medical treatment options should be
administered for a minimum of 3 months, with evaluation of efficacy
at the end of the trial period.
L.ZA.MKT.10.2018.2951
References: 1. Leyland N, et al. SOGC Clinical Practice Guideline. J Obstet Gynecol Can 2010; 32 (7 Suppl 2): S1-S32. 2. Johnson L, Hummelshoj L. for WES. Consensus on current management of endometriosis. Human Reproduction 2013; 28(6):1552-1568
Surgery
Surgical management in women with endometriosis- related pain
should be reserved for those in whom medical treatment has
failed.1
The issue of appropriate laparoscopic surgical training is
considered vital and there are strong arguments for
standardization of what constitutes the relevant experience and
expertise for those undertaking complex laparoscopic surgery for
endometriosis.2
Crucial aspects in planning laparoscopic surgery are that surgery
should be carried out in the most appropriate setting which can
ensure adequate preoperative counselling, appropriate surgical
expertise (to ensure the most appropriate procedure is
undertaken by the most experienced surgeon at the most
appropriate time), adequate technical resources and
postoperative support care.
First operations tend to produce a better response
than subsequent surgical procedures, with pain
improvements at 6 months in the region of 83% for first excisional
procedures versus 53% for second procedures.2

23. #SpeakUpAboutEndometriosis
When is surgery indicated?
Reference: Leyland N, et al. SOGC Clinical Practice Guideline. Endometriosis: Diagnosis and Management. J Obstet Gynecol Can 2010; 32 (7 Suppl 2): S1-S32.
L.ZA.MKT.10.2018.2951
pelvic pain unresponsive to medical treatment
contraindications to medical treatment
acute emergencies
Deep Infiltrating Endometriosis (after failed medical
management)
suspicion of malignancy
compromised organ functions
infertility and associated factors
Laparoscopy should ideally be diagnostic and therapeutic1
Surgical management in women with endometriosis-related pain should be reserved for those in
whom medical treatment has failed. Laparoscopy should generally be performed only if the
surgeon is prepared to remove lesions if endometriosis is discovered.1
At the right time for the patient

24. #SpeakUpAboutEndometriosis
Recurrence of endometriosis in patients
after endometriosis-related surgery.
Recurrence after
endometriosis-related
surgery remains a
formidable challenge1
Estimated recurrence rates2:
2 Years = 22% 5 Years = 40 - 50%
Reference: Guo S-W. Recurrence of endometriosis and its control. Hum Reprod Update 2009; 15(4):441-461. L.ZA.MKT.10.2018.2951

25. #SpeakUpAboutEndometriosis
Recurrence = Repeat Surgery?
Re-operation occurs in > 50% of
patients with endometriosis;
With about 27% of these patients
requiring > 3 surgeries1
Repeat surgery is associated with:
increased complications,
negative impact on quality of
life, and
in ovarian endometriosis with
damage to the ovarian
reserve1,3
International guidelines recognize
the importance of post-surgical
medical therapy to minimize
recurrence of endometriosis2,3,4
References: 1. Guo S. Recurrence of endometriosis and its control. Human Reproduction Update. 2009; 15(4): 441–461. 2. Dunselman G, et al. ESHRE guideline: management of
women with endometriosis. Human Reproduction 2014; 29(3):400–412. 3 . Leyland N, et al. SOGC Clinical Practice Guideline. Endometriosis: Diagnosis and Management. J
Obstet Gynecol Can 2010; 32 (7 Suppl 2): S1-S32. 4. . Johnson N, Hummelshoj L. WES Consensus on current management of endometriosis. Human Reproduction 2013; 28 (6):
1552–1568. L.ZA.MKT.10.2018.2951

26. #SpeakUpAboutEndometriosis
Remember the aims of management!
The aims of long-term treatment or management strategies in
women who have undergone first-line procedures for endometriosis
are:
Preserving the residual reproductive potential,
preventing recurrences
and avoiding serial surgery.
Vercellini P, et al. Post-operative endometriosis recurrence: a plea for prevention based on pathogenetic, epidemiological and clinical evidence. Reprod
Biomed Online 2010; 21:259–265. L.ZA.MKT.10.2018.2951

27. #SpeakUpAboutEndometriosis
The Effect of Surgery for Endometriomas on Fertility
It is well known that the presence of an endometrioma, as well as
its removal, may be detrimental for future fertility.
It has also been shown that the likelihood of conception after
second surgery is almost half that after a primary procedure.
The probability of conception after second surgery for
endometriosis appears to be around 25% compared with around
40% after primary procedures.
Therefor,avoiding repetitive damage to the ovaries of women
with endometriosis would be essential in order to preserve the
already reduced reproductive potential.
Vercellini P, et al. Post-operative endometriosis recurrence: a plea for prevention based on pathogenetic, epidemiological and clinical evidence. Reprod
Biomed Online 2010; 21:259–265. L.ZA.MKT.10.2018.2951

28. #SpeakUpAboutEndometriosis
A Lifelong care plan is required
Medical Management The IDEAL Surgery Long-term plan
Pain
Fertility or
Failed Med Rx,
Surgery at the
Right Time for
the Right
Patient1
Because endometriosis is a chronic,
relapsing disorder, doctors should
develop a long-term plan of
management with each patient, until the
patient wishes to become pregnant,
avoid surgery if possible and continue
long-term management until
menopause.2
References: 1. Leyland N, et al. SOGC Clinical Practice Guideline. Endometriosis: Diagnosis and Management. J Obstet Gynecol Can 2010; 32 (7 Suppl 2): S1-S32. 2.
Ota Y, et al. Long-term administration of dienogest reduces recurrence after excision of endometrioma. J Endometriosis Pelvic Pain Disorders 2015; 7(2): 63-67.
L.ZA.MKT.10.2018.2951

29. #SpeakUpAboutEndometriosis
What is a Prescribed Minimum Benefit (PMB) ?
Prescribed Minimum Benefits (PMBs) are a set of defined
benefits to ensure that all medical aid members have access
to certain minimum health services, regardless of the
benefit option they have selected (including hospital plans).
They were introduced into the Medical Schemes Act to
ensure that members of medical aids would not run out of
benefits for certain conditions and find themselves forced to
go to State hospitals for treatment.
These PMBs cover a wide range of ± 270 conditions.
However, take note that certain limitations could apply, such
as the use of a Designated Service Provider (DSP) and
specified treatment standards.
Reference: Council For Medical Schemes. Definition: What are PMBs? Available from: http://www.medicalschemes.com/ medical_schemes_pmb/index.htm. [Accessed
30 August 2018]. L.ZA.MKT.10.2018.2951

30. #SpeakUpAboutEndometriosis
How is endometriosis viewed by the medical aid?
Endometriosis is a prescribed minimum benefit (PMB) condition under PMB / DTP code 434M
(Non- inflammatory disorders and benign neoplasms of ovary, fallopian tubes and uterus).
Endometriosis in other areas is not included in the current PMB regulations.
This implies that the medical scheme should fund the costs associated with the diagnosis and
treatment of endometriosis if the correct code is used.
The DTP covers the cost of medical and surgical management of endometriosis, with explicit
mention of the following surgical procedures:
Salpingectomy (surgical removal of the fallopian tube),
Oophorectomy (surgical removal of one or both ovaries) and
Hysterectomy (surgical removal of all or part of the womb).
Laparoscopy can be used to diagnose, to identify the stage of endometriosis, and to remove the
abnormally deposited tissue. Laparoscopy should be funded as PMB level of care.
Some medical schemes have Designated Service Provider (DSP) arrangements and protocols
in place which should be verified and discussed with the medical scheme prior to either
diagnostic procedures or treatment is started.
Reference: Maramba E. Endometriosis. CMScript. 2016; 8:1-4. L.ZA.MKT.10.2018.2951

31. #SpeakUpAboutEndometriosis
What is an ICD-10 code and what does it mean?
Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD
-10-CM codes
ICD-10 stands for International Classification of Diseases and Related Health Problems (10th revision).
It is a coding system developed by the World Health Organisation (WHO), that translates the written description
of medical and health information into standard codes, e.g. N80.9 is an ICD-10 code for endometriosis.
ICD-10 codes are used to inform medical schemes about what conditions their members were treated for so that
claims can be settled correctly.
When you join a medical scheme, you choose and pay for a particular benefit option. This benefit option contains
a basket of services that often has limits on the health services that will be paid for.
Because ICD-10 codes provide accurate information on the condition you have been diagnosed with, these codes
help the medical scheme to determine what benefits you are entitled to and how these benefits could be paid.
This becomes very important if you have a PMB condition, such as endometriosis, as these can only be identified
by the correct ICD-10 codes.
Therefore, if the incorrect ICD-10 codes are recorded on your invoices, referral letters, medicine prescription etc.
your PMB-related services (e.g. diagnosis and treatment) might be paid from the wrong benefit (such as from
your medical savings account), or it might not be paid at all if your day-to-day or hospital benefits limits have
been exhausted.
Reference: Council For Medical Schemes. ICD-10 Codes. Available from: http://www.medicalschemes.com/ medical_schemes_pmb/ICD-
10_codes.htm. [Accessed 30 August 2018]. L.ZA.MKT.10.2018.2951

32. #SpeakUpAboutEndometriosis
What are the ICD-10 codes for Endometriosis?
N80 Endometriosis
N80.0 Endometriosis of uterus
N80.1 Endometriosis of ovary
N80.2 Endometriosis of fallopian tube
N80.3 Endometriosis of pelvic peritoneum
N80.4 Endometriosis of rectovaginal septum and vagina
N80.5 Endometriosis of intestine
N80.6 Endometriosis in cutaneous scar
N80.8 Other endometriosis
N80.9 Endometriosis, unspecified
ICD - 10
N 8 0 1
Category
(endometriosis)
Body Part
(ovary)
Section
(Diseases of the
genitourinary
system)
Reference: Council For Medical Schemes. ICD-10 Codes. Available from: http://www.medicalschemes.com/ medical_schemes_pmb/ICD-10_codes.htm
http://www0.sun.ac.za/aotc/icd10/mf_icd10_codelist.php?cmd=search&t=mf_icd10_code&psearch=N80&btnsubmit=Search+%28*%29&psearchtype
=AND. L.ZA.MKT.10.2018.2951
PMB

33. #SpeakUpAboutEndometriosis
What is a Designated Service Provider (DSP)?
A Designated Service Provider (DSP) is ahealthcare provider (doctor, pharmacist, hospital, etc.)
that is a medical scheme’s first choice when its members need diagnosis, treatment or care for
a PMB condition.
If you choose not to use the DSP selected by your scheme, you may have to pay a portion of
the bill as a co-payment. This could either be a percentage co-payment or the difference
between the DSP’s tariff and that charged by the provider you went to.
Medical schemes have to ensure that it is easy for beneficiaries to get to the DSPs. If there is no
DSP within reasonable distance of your work or home, then you can visit any provider and the
scheme is obliged to pay.
When you suffer an emergency condition, or are involved in an accident, you may go to the
nearest healthcare facility for treatment, even if it is not a DSP. Your scheme will have to cover
the costs.
Schemes also have to ensure that the DSPs of their choice can deliver the services needed
and without members having to wait unreasonably long. Where a DSP is unable to
accommodate or treat a member, the medical scheme remains liable for all the costs of
treating the PMB condition at a non-DSP.
Reference: Council For Medical Schemes. Designated Service Providers. Available from: http://www.medicalschemes.com/ CMS Website
medical_schemes_pmb/designated_service_providers.htm. [Accessed 30 August 2018]. L.ZA.MKT.10.2018.2951

34. #SpeakUpAboutEndometriosis
What can you as a Patient take Responsibility for?
Remember that you as a patient made the decision about the medical aid selected and the option within the
medical aid e.g. hospital plan only.
Educate yourself about your medical scheme’s rules, the listed medication and treatments (formularies) for
endometriosis, as well as if and who the Designated Service Providers are.
Doctors do not usually have a direct contractual relationship with medical schemes. They merely issue their
accounts and if the medical scheme does not pay, for whatever reason, the doctor turns to the patient for the
amount due. This does not mean that PMBs are not important to healthcare providers nor that they don’t
have a role to play in its successful functioning.
Reimbursement claims require the use of ICD-10-CM codes. Make sure the correct ICD 10 code appears on
all your invoices, referral letters, prescriptions etc.
If you use the correct ICD-10 code your account will be paid as PMBs enjoy guaranteed medical aid cover. If
you have been given a treatment, or choose a treatment, that is not on your medical aid’s formulary
you might have to pay in towards the treatment (a co-payment) but you are entitled to some financial cover.
Follow up and check that your account is submitted within four months and paid within 30 days
after the claim was received (accounts older than four months are not paid by medical schemes).
Reference: Council For Medical Schemes. Responsibilities. Available from: http://www.medicalschemes.com/ medical_schemes_pmb/responsibility.htm.
[Accessed 30 August 2018]. L.ZA.MKT.10.2018.2951

35. #SpeakUpAboutEndometriosis
Levy AR, et al. Economic Burden of Surgically Confirmed Endometriosis in Canada. J Obstet Gynaecol Can 2011;33(8):830-837. L.ZA.MKT.10.2018.2951

36. #SpeakUpAboutEndometriosis
Where can endometriosis patients go for Support?
Endometriosis support groups provide a valuable forum for women with endometriosis, having the potential to assist
women to improve their quality of life by teaching coping mechanisms and sharing experiences. (World Endometriosis
Society Guidelines; 2011)
South African Endometriosis Support https://m.facebook.com/groups/1319002964863357)
Endometriosis Warriors South Africa (https://www.facebook.com/endowarrior/)
Foundation For Endometriosis Awareness, Advocacy and Support (https://www.endometriosisawareness.co.za)
Endometriosis Foundation of Africa (https://www.facebook.com/Endometriosisfoundationofafrica)
Endometriosis Support South Africa
The Botswana Endometriosis Foundation (https://www.facebook.com/BotswanaEndometriosisFoundation/)
#SpeakUpAboutEndometriosis – use the #tag to raise awareness and increase dialogue
L.ZA.MKT.10.2018.2951

37. #SpeakUpAboutEndometriosis
Thank you
“Endometriosis affects women during the prime years of their lives,
a time when they should be finishing an education, starting and
maintaining a career, building relationships and perhaps have a
family.
For these women to have their productivity affected, their quality of
life compromised and their chances for starting a family reduced, is
something society can no longer afford to ignore.
It is time we see serious investment in preventing this debilitating
condition in the next generation of women.”
Dr Stephen Kennedy – Professor of Reproductive Medicine
L.ZA.MKT.10.2018.2951