People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Using inclusive language in healthcare is important for safety, and to promote equity, respect and effective communication with everyone. This guideline does not use inclusive language in whole or in part because:
the evidence has not been reviewed, and it is not certain from expert opinion which groups the advice covers, or
the evidence has been reviewed, but the information available for some groups was too limited to make specific recommendations, or
only a very limited number of recommendations have been updated in direct response to new evidence or to reflect a change in practice.
Healthcare professionals should use their clinical judgement when implementing recommendations, taking into account the individual's circumstances, needs and preferences, and ensuring all people are treated with dignity and respect throughout their care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
Set up a managed clinical network for women with suspected or confirmed endometriosis, consisting of community services (including GPs, practice nurses, school nurses and sexual health services), gynaecology services (see the recommendation on gynaecology services) and specialist endometriosis services (see the recommendation on specialist endometriosis services [endometriosis centres]). [2017]
Community, gynaecology and specialist endometriosis services (endometriosis centres) should:
provide coordinated care for women with suspected or confirmed endometriosis
have processes in place for prompt diagnosis and treatment of endometriosis, because delays can affect quality of life and result in disease progression. [2017]
Gynaecology services for women with suspected or confirmed endometriosis should have access to:
a gynaecologist with expertise in diagnosing and managing endometriosis, including training and skills in laparoscopic surgery
a gynaecology specialist nurse with expertise in endometriosis
a multidisciplinary pain management service
a healthcare professional with an interest in gynaecological imaging
fertility services. [2017]
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. [2017]
Be aware that endometriosis can be a long-term condition, and can have a significant physical, sexual, psychological and social impact. Women may have complex needs and require long-term support. [2017]
Assess the individual information and support needs of women with suspected or confirmed endometriosis, taking into account their circumstances, symptoms, priorities, desire for fertility, aspects of daily living, work and study, cultural background, and their physical, psychosexual and emotional needs. [2017]
Provide information and support for women or people with suspected or confirmed endometriosis, which should include:
what endometriosis is
endometriosis symptoms and signs
how endometriosis is diagnosed and the pathway of care, including referral criteria
treatment and management options
local support groups, online forums and national charities, and how to access them.
Ensure that information is provided and updated throughout the woman or person's care journey, and that it is appropriate for the stage they are at in their care. [2017, amended 2024]
If women agree, involve their partner (and/or other family members or people important to them) and include them in discussions. For more guidance on providing information to people and involving family members and carers, see the NICE guideline on patient experience in adult NHS services. [2017]
Suspect endometriosis in women (including young women aged 17 and under) presenting with 1 or more of the following symptoms or signs:
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. [2017]
Ask if any first-degree relatives have a history of endometriosis, as this increases the likelihood of endometriosis. [2024]
Inform women with suspected or confirmed endometriosis that keeping a pain and symptom diary can aid discussions. [2017]
Take into account that every person's experience of pain is unique to them and may be expressed in different ways, both verbally and non-verbally. In particular, this may vary because of:
their cultural background and beliefs
their socioeconomic status
any neurodiverse conditions they may have. [2024]
Offer an abdominal and pelvic (internal vaginal) examination to women and people with suspected endometriosis to identify abdominal masses and pelvic signs, such as reduced organ mobility and enlargement, tender nodularity in the posterior vaginal fornix, and visible vaginal endometriotic lesions. [2017, amended 2024]
Offer an abdominal examination to exclude abdominal masses if a pelvic (internal vaginal) examination is declined, or not suitable for the person. [2017, amended 2024]
For a short explanation of why the committee made the new and updated 2024 recommendations and how they might affect practice, see the rationale and impact section on endometriosis signs and symptoms.
Full details of the evidence and the committee's discussion are in evidence review B: diagnosing endometriosis.
For women with endometriosis-related pain, discuss the benefits and risks of analgesics, taking into account any comorbidities and the woman's preferences. [2017]
Consider a short trial (for example, 3 months) of paracetamol or a non-steroidal anti-inflammatory drug (NSAID) alone or in combination for first-line management of endometriosis-related pain. [2017]
If a trial of paracetamol or an NSAID (alone or in combination) does not provide adequate pain relief, consider other forms of pain management and referral for further assessment. [2017]
For recommendations on using neuromodulators to treat neuropathic pain, see the NICE guideline on neuropathic pain in adults. [2017]
Explain to women with suspected or confirmed endometriosis that hormonal treatment for endometriosis can reduce pain and has no permanent negative effect on subsequent fertility. [2017]
Offer hormonal treatment (for example, the combined oral contraceptive pill or a progestogen) to women with suspected, confirmed or recurrent endometriosis. [2017]
In September 2017, this was off-label use for some combined oral contraceptive pills or progestogens. See NICE's information on prescribing medicines.
Carry out additional investigations such as ultrasound and referral (if necessary, see recommendations 1.5.5 to 1.5.7) in parallel with each other, and in conjunction with initial pharmacological treatment. [2024]
Offer a transvaginal ultrasound scan to all women or people with suspected endometriosis, even if pelvic or abdominal examination is normal, to:
identify ovarian endometriomas and deep endometriosis, including that involving the bowel, bladder or ureter
identify or rule out other pathology which may be causing symptoms
guide management options and enable referral to an appropriate service, depending on the ultrasound findings. See recommendations 1.5.5 to 1.5.7.
This ultrasound scan should be organised by the person's general practice. [2024]
If a transvaginal ultrasound scan is declined or not suitable for the person, consider a transabdominal ultrasound scan of the pelvis. [2017, amended 2024]
Do not exclude the possibility of endometriosis if the abdominal or pelvic examination and ultrasound scan are normal, and recognise that referral may still be necessary even with a normal scan. [2017, amended 2024]
Refer women or people with symptoms of, or confirmed, endometriosis to a gynaecology service (see the recommendation on gynaecology services) for further investigation and management if:
initial treatment is not effective, is not tolerated or is contraindicated, or
they have symptoms of endometriosis which have a detrimental impact on activities of daily living, or
they have persistent or recurrent symptoms of endometriosis, or
they have pelvic signs of endometriosis, but deep endometriosis is not suspected. [2017, amended 2024]
Refer women or people to a specialist endometriosis service (see the recommendation on specialist endometriosis services [endometriosis centre]) if they have suspected or confirmed:
endometrioma, or
deep endometriosis, including that involving the bowel, bladder or ureter, or
endometriosis outside the pelvic cavity. [2017, amended 2024]
Refer young women or people (aged 17 and under) with suspected or confirmed endometriosis to a paediatric and adolescent gynaecology service or specialist endometriosis service (endometriosis centre) for further investigation and management. [2017, amended 2024]
Do not use serum CA125 to diagnose endometriosis. [2017]
Consider specialist transvaginal ultrasound scan or pelvic MRI scan to diagnose deep endometriosis and assess its extent. [2017, amended 2024]
Ensure that specialist transvaginal ultrasound scans and pelvic MRI scans are planned and interpreted by a healthcare professional with specialist expertise in gynaecological imaging. [2017, amended 2024]
Also refer to the section on surgical management and the section on management if fertility is a priority.
Consider laparoscopy to diagnose endometriosis in women or people with suspected endometriosis, even if the ultrasound scan or MRI scan was normal. [2017, amended 2024]
For women or people with suspected deep endometriosis consider a specialist pelvic ultrasound scan or MRI scan before an operative laparoscopy. [2017, amended 2024]
During a diagnostic laparoscopy, a gynaecologist with training and skills in laparoscopic surgery for endometriosis should perform a systematic inspection of the pelvis and record the findings (including normal and abnormal areas and intra-operative imaging). [2017, amended 2024]
During a diagnostic laparoscopy, consider taking a biopsy of suspected endometriosis:
to confirm the diagnosis of endometriosis (be aware that a negative histological result does not exclude endometriosis)
to exclude malignancy if an endometrioma is treated but not excised. [2017]
If a systematic laparoscopy with recorded findings of normal and abnormal areas and intra-operative imaging is performed and is normal, explain to the woman or person that it is unlikely that they have endometriosis, and offer alternative management of their symptoms. [2017, amended 2024]
For a short explanation of why the committee made the new and updated 2024 recommendations and how they might affect practice, see the rationale and impact section on diagnosis of endometriosis.
Full details of the evidence and the committee's discussion are in evidence review B: diagnosing endometriosis.
Offer endometriosis treatment according to the woman's symptoms, preferences and priorities, rather than the stage of the endometriosis. [2017]
When endometriosis is diagnosed, the gynaecologist should document a detailed description of the appearance and site of endometriosis. [2017]
Consider outpatient follow‑up (with or without examination and pelvic imaging) for women with confirmed endometriosis, particularly women who choose not to have surgery, if they have:
deep endometriosis involving the bowel, bladder or ureter or
1 or more endometrioma that is larger than 3 cm. [2017]
Advise women that the available evidence does not support the use of traditional Chinese medicine or other Chinese herbal medicines or supplements for treating endometriosis. [2017]
Ask women with suspected or confirmed endometriosis about their symptoms, preferences and priorities with respect to pain and fertility, to guide surgical decision-making. [2017]
Discuss surgical management options with women with suspected or confirmed endometriosis. Discussions may include:
what a laparoscopy involves
that laparoscopy may include surgical treatment (with prior patient consent)
how laparoscopic surgery could affect endometriosis symptoms
the possible benefits and risks of laparoscopic surgery
the possible need for further surgery (for example, for recurrent endometriosis or if complications arise)
the possible need for further planned surgery for deep endometriosis involving the bowel, bladder or ureter. [2017]
Perform surgery for endometriosis laparoscopically, unless there are contraindications. Record the results with intra-operative imaging. [2017, amended 2024]
During a laparoscopy to diagnose endometriosis, consider laparoscopic treatment of the following, if present:
peritoneal endometriosis not involving the bowel, bladder or ureter
uncomplicated ovarian endometriomas. [2017]
As an adjunct to surgery for deep endometriosis involving the bowel, bladder or ureter, consider 3 months of gonadotrophin-releasing hormone agonists before surgery. [2017]
In September 2017, this was off-label use for some gonadotrophin-releasing hormone agonists. See NICE's information on prescribing medicines.
Consider excision rather than ablation to treat endometriomas, taking into account the woman's desire for fertility and her ovarian reserve. Also see the section on ovarian reserve testing in the NICE guideline on fertility problems. [2017]
After laparoscopic excision or ablation of endometriosis, consider hormonal treatment (with, for example, the combined oral contraceptive pill), to prolong the benefits of surgery and manage symptoms. [2017]
In September 2017, this was off-label use for some hormonal treatments (including some combined oral contraceptive pills). See NICE's information on prescribing medicines.
If hysterectomy is indicated (for example, if the woman has adenomyosis or heavy menstrual bleeding that has not responded to other treatments), excise all visible endometriotic lesions at the time of the hysterectomy. [2017]
Perform hysterectomy (with or without oophorectomy) laparoscopically when combined with surgical treatment of endometriosis, unless there are contraindications. [2017]
For women thinking about having a hysterectomy, discuss:
what a hysterectomy involves and when it may be needed
the possible benefits and risks of hysterectomy
the possible benefits and risks of having oophorectomy at the same time
how a hysterectomy (with or without oophorectomy) could affect endometriosis symptoms
that hysterectomy should be combined with excision of all visible endometriotic lesions
endometriosis recurrence and the possible need for further surgery
the possible benefits and risks of hormone replacement therapy after hysterectomy with oophorectomy (also see the NICE guideline on menopause).[2017]
The recommendations in this section should be interpreted within the context of NICE's guideline on fertility problems. The management of endometriosis-related subfertility should have multidisciplinary team involvement with input from a fertility specialist and access to fertility services. Depending on the severity of the endometriosis this may be in a secondary care gynaecology service or a tertiary care specialist endometriosis service.
This should include the recommended diagnostic fertility tests or preoperative tests, as well as other recommended fertility treatments such as assisted reproduction that are included in the NICE guideline on fertility problems.
Offer excision or ablation of endometriosis plus adhesiolysis for endometriosis not involving the bowel, bladder or ureter, because this improves the chance of spontaneous pregnancy. [2017]
Offer laparoscopic ovarian cystectomy with excision of the cyst wall, or laparoscopic drainage and ablation, to women or people with endometriomas, because this improves the chance of spontaneous pregnancy. Take into account:
the possible impact on ovarian reserve
that ablation and drainage may preserve ovarian reserve more than cystectomy (also see the section on ovarian reserve testing in the NICE guideline on fertility problems). [2017, amended 2024]
Discuss the benefits and risks of laparoscopic surgery as a treatment option with women or people who have deep endometriosis (including endometriosis that involves the bowel, bladder or ureter) and who are trying to conceive so they can make an informed decision on its use. Topics to discuss may include:
the possible impact of deep endometriosis on pregnancy outcomes
whether laparoscopic surgery may alter the chance of future pregnancy
the possible impact on fertility if complications arise
alternatives to surgery
other fertility factors. [2017, amended 2024]
Do not offer hormonal treatment alone or in combination with surgery to women or people with endometriosis who are trying to conceive, because it does not improve spontaneous pregnancy rates. [2017, amended 2024]
For a short explanation of why the committee made the updated 2024 recommendations and how they might affect practice, see the rationale and impact section on treatment of endometriosis when fertility is a priority.
Full details of the evidence and the committee's discussion are in evidence review A: treatment of endometriosis when fertility is a priority.
Defined as pelvic pain lasting for 6 months or longer.
Paediatric and adolescent gynaecology services are hospital-based, multidisciplinary specialist services for girls and young women (usually aged under 18).
Ovarian cystectomy is a surgical excision of an ovarian endometriotic cyst. An ovarian endometrioma is a cystic mass arising from ectopic endometrial tissue within the ovary.
Linked groups of healthcare professionals from primary, secondary and tertiary care providing a coordinated patient pathway. Responsibility for setting up these networks will depend on existing service provision and location.