BLOG : A Focus On Women's Health & Endometriosis - What Happens Next?

05th, Mar 2025

Continuing on from part 1, we delve deeper into what happens next when it comes to testing and treatment for endometriosis. Let's go!

What happens next?

After your GP assessment, you can either explore treatment through your GP or seek a referral to a specialist for a confirmed diagnosis.

Recent European guidelines highlight both options as reasonable, and the best course of action should be discussed with the patient.

When is referral necessary?

According to guidelines from the National Institute for Health and Care Excellence (NICE), referral to a specialist should be considered if:

Symptoms are severe, persistent, or recurring
Initial treatments in primary care are ineffective, unsuitable, or poorly tolerated
A doctor identifies pelvic abnormalities during an examination

Additionally, referrals are recommended for suspected endometriosis involving the bowels, bladder, or ureters (the tubes that connect the kidneys to the bladder). Abnormal ultrasound findings, such as an ovarian cyst, usually prompt a referral. Sometimes the scan might be repeated in six to eight weeks to monitor changes in the cyst's size.

If you’re trying to conceive or planning to in the near future, an early referral is often advised. Many primary care treatments are contraceptive and not suitable for those looking to become pregnant. Furthermore, individuals with endometriosis may require additional assistance with fertility, so addressing this early can be beneficial.

Treating endometriosis in primary care

For mild symptoms or cases where referral isn’t needed, your GP may suggest one or more of the following treatments:

Paracetamol: This can be effective for mild symptoms, especially when taken during periods.

Anti-inflammatory medications: Ibuprofen, diclofenac, naproxen, or mefenamic acid may relieve pain more effectively than paracetamol. However, they can cause side effects and are unsuitable for people with a history of stomach or intestinal ulcers.

Codeine: This stronger painkiller can be used alone or combined with paracetamol. It’s an alternative if anti-inflammatory medications are unsuitable, though it commonly causes constipation.

For best results, take pain relief medication regularly during your period rather than sporadically. You can combine painkillers with other treatments.

Although not a painkiller, tranexamic acid may also help.

Hormone Therapies for Endometriosis

A variety of hormone treatments are available for endometriosis, many of which are effective in alleviating pain. Some options also act as contraceptives during use but don’t impact future fertility.

Combined Hormonal Contraception (CHC): Available as a pill (commonly referred to as birth control pills), patch, or vaginal ring.
Progestogen-Only Contraception: Provided as a pill, implant, or depot injection.
Levonorgestrel Intrauterine Device (LNG-IUD): A hormonal device placed in the uterus.
Progestogen Hormone Tablets: These include norethisterone, dydrogesterone, and medroxyprogesterone. Note that these may not always work as contraceptives, so if pregnancy prevention is required, additional contraception will be necessary to manage symptoms effectively.

If symptom relief is not achieved with initial treatment from your primary care doctor, you may be referred to a gynaecologist. In the interim, it’s often possible to try a different treatment while awaiting your appointment.

Overall, all hormone therapies have a similar success rate in managing pain, but individual responses can vary. Some women find one option works better than others. Additionally, not all women are suitable candidates for every therapy. For instance, women with a history of blood clots or certain types of migraines are unable to use CHC.

What Happens if I’m referred for suspected endometriosis?

You will see a gynaecologist with a special interest in Endometriosis. They may recommend:

Specialist Tests

MRI Scans: A pelvic MRI might be used to check for deep endometriosis in areas such as the bladder, bowel, or ureters (the tubes connecting the kidneys to the bladder). However, some endometriosis types are not visible with an MRI, so a normal result doesn’t entirely rule it out.

Surgical Diagnosis (Laparoscopy): The only way to definitively diagnose endometriosis is through a laparoscopy. This minor surgery involves making a small incision under general anesthesia, near the belly button. A thin, telescope-like instrument (laparoscope) is inserted through the skin to examine the abdominal cavity. If found, patches of endometriosis can often be treated during the same procedure.

While minimally invasive, a laparoscopy carries some risks but offers the dual benefit of diagnosing and treating endometriosis simultaneously.

What happens if endometriosis remains untreated?

The progression of untreated endometriosis varies widely - symptoms might improve, remain stable, or worsen over time. Importantly, endometriosis is not a cancerous condition.

In severe, untreated cases, complications may arise. For example, extensive patches of endometriosis can lead to blockages in the bowel or ureters.

What are the treatment options for endometriosis?

If symptoms are mild and fertility is not a concern, you might decide against treatment. However, treatment can remain an option in the future if symptoms worsen or persist.

The primary goals of treatment are pain relief, management of heavy periods, and improved fertility for those experiencing difficulties.

Surgery for Endometriosis

Surgery is sometimes necessary to confirm the diagnosis and address larger patches of endometriosis. Surgical intervention can alleviate symptoms and, in some cases, enhance fertility.

Most procedures involve laparoscopy, allowing surgeons to visually examine and remove problematic tissue through a small incision.

An alternative to tissue excision is ablation, where heat or laser techniques destroy endometriosis tissue. During surgery, ovarian cysts related to endometriosis (sometimes called “chocolate cysts” due to their appearance) can also be removed.

Surgeons often seek pre-procedure consent to treat patches found during diagnosis, avoiding the need for multiple laparoscopies. In rare cases, a more traditional, larger abdominal incision may be required for extensive endometriosis or cyst removal.

Hysterectomy for Endometriosis

For women certain they do not want children in the future, and when other treatments have not provided relief, hysterectomy (removal of the uterus) may be an option. This is major surgery and does not guarantee symptom resolution. Discussions about risks and benefits with a consultant are essential.

Removing the ovaries during a hysterectomy significantly reduces the chance of endometriosis recurrence but induces permanent early menopause. Hormone Replacement Therapy (HRT) may be necessary to manage menopausal symptoms and prevent osteoporosis. Most women need only estrogen-based HRT, but women with a hysterectomy due to endometriosis may require a combination of estrogen and progestogen. Ensure your GP is aware of your medical history.

Other Treatments: A specialist consultant may recommend additional treatments not typically initiated by GPs, including:
Gonadotrophin-Releasing Hormone (GnRH) Analogues: Examples include buserelin, goserelin, nafarelin, leuprorelin, and triptorelin, which induce temporary menopause. ‘Add-back’ HRT may accompany these treatments to minimize menopausal side effects.
Aromatase Inhibitors: Such as letrozole.
Danazol: An additional hormone therapy option.
Recurrence: Even after successful treatment, endometriosis may return. If symptoms reappear, further or combined treatment options may be necessary.

Seeking Help

If symptoms are severe, persistent, or impact your fertility, a referral to a specialist may be necessary. A gynaecologist can offer advanced treatments and surgical options to manage the condition effectively.

While endometriosis is a chronic condition, the right treatment plan can help improve quality of life and fertility outcomes. If you’re experiencing symptoms, don’t hesitate to speak with a healthcare professional.

Dr. Lisa Neligan, Clinical lead GP Kingsbridge Private Hospital