Quality standard
Quality statement 2: Referral after initial treatment
Quality statement 2: Referral after initial treatment
Quality statement
Women and people are referred to a gynaecology service if initial treatment for endometriosis is not effective, not tolerated or contraindicated.
Rationale
Initial treatment for endometriosis is usually given in primary care after a working diagnosis of endometriosis has been made. Referral to a gynaecology service if initial treatment is not effective, not tolerated or contraindicated allows further investigation and management options to be explored. This can reduce the possibility of women and people experiencing significant, prolonged ill health and distress, and improve their quality of life. Referral is made to a gynaecology service, or to a paediatric and adolescent gynaecology service or specialist endometriosis service, depending on the woman or person's age.
Quality measures
The following measure can be used to assess the quality of care or service provision specified in the statement. It is an example of how the statement can be measured, and can be adapted and used flexibly.
Process
Proportion of women and people in whom initial treatment for endometriosis is not effective after 6 months, not tolerated or contraindicated who are referred to a gynaecology service.
Numerator – the number in the denominator who are referred to a gynaecology service.
Denominator – the number of women and people in whom initial treatment for endometriosis is not effective after 6 months, not tolerated or contraindicated.
Data source: Local data collection, for example primary care referral records.
What the quality statement means for different audiences
Service providers (such as GP practices) ensure that systems are in place for women and people to be referred to a gynaecology service if initial treatment for endometriosis is not effective, not tolerated or contraindicated. Referrals will be made to a gynaecology service for women and people aged 18 and over. Young women and people aged 17 and under will be referred to a specialist endometriosis service or paediatric and adolescent gynaecology service.
Healthcare professionals (such as GPs and practitioners in emergency departments) are aware of the local referral pathways for women and people in whom initial treatment for endometriosis is not effective, not tolerated or contraindicated. They refer women and people aged 18 and over to a gynaecology service. They refer young women and people aged 17 and under to a specialist endometriosis service or paediatric and adolescent gynaecology service.
Commissioners ensure that they commission secondary and tertiary services that include the necessary healthcare professionals to diagnose and treat endometriosis (gynaecology service, specialist endometriosis service or paediatric and adolescent gynaecology service).
Women and people with signs and symptoms of endometriosis are referred for further investigation and management if the symptoms are not relieved by the initial treatment, or if they are not able to have treatment, for example if they are trying to conceive. Women and people aged 18 and over are referred to a gynaecology service. Young women and people aged 17 and under are referred to a specialist endometriosis service or paediatric and adolescent gynaecology service.
Source guidance
Endometriosis: diagnosis and management. NICE guideline NG73 (2017, updated 2024), recommendations 1.5.5 and 1.5.7
Definitions of terms used in this quality statement
Initial treatment that is not effective
For measurement purposes, a 6-month timescale can be used to decide whether initial treatment is effective. However, a referral should be made before 6 months if it becomes clear that treatment is not effective. [Expert opinion]
Gynaecology service
Women and people can be referred to one of the following services:
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general gynaecology service
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specialist endometriosis service (endometriosis centre)
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paediatric and adolescent gynaecology service.
[Adapted from NICE's guideline on endometriosis, recommendations 1.5.5 and 1.5.6]
Gynaecology services for women and people aged 18 and over with suspected or confirmed endometriosis
Gynaecology services for women and people with suspected or confirmed endometriosis have access to:
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a gynaecologist with expertise in diagnosing and managing endometriosis, including training and skills in laparoscopic surgery
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a gynaecology specialist nurse with expertise in endometriosis
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a multidisciplinary pain management service
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a healthcare professional with an interest in gynaecological imaging
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fertility services.
[Adapted from NICE's guideline on endometriosis, recommendation 1.1.3]
Specialist endometriosis service (endometriosis centre)
Specialist endometriosis services (endometriosis centres) have access to:
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gynaecologists with expertise in diagnosing and managing endometriosis, including advanced laparoscopic surgical skills
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a colorectal surgeon with an interest in endometriosis
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a urologist with an interest in endometriosis
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an endometriosis specialist nurse
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a multidisciplinary pain management service with expertise in pelvic pain
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a healthcare professional with specialist expertise in gynaecological imaging of endometriosis
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advanced diagnostic facilities (for example, radiology and histopathology)
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fertility services.
[Adapted from NICE's guideline on endometriosis, recommendation 1.1.4]
Paediatric and adolescent gynaecology service
Paediatric and adolescent gynaecology services are hospital-based, multidisciplinary specialist services for girls, young women and people (usually aged under 18). [NICE's guideline on endometriosis, terms used in this guideline]
Equality and diversity considerations
Transgender men should be referred to gynaecology services if endometriosis is suspected because initial treatment for endometriosis may be contraindicated. Some transgender men may find it distressing to attend appointments in a women's hospital or dedicated women's unit and may need to be seen in another clinic or setting.
Some services, such as paediatric and adolescent gynaecology services and specialist endometriosis services, may not be available in all local areas. This should not prevent access to appropriate care.