The National Institute of Health and Care Excellence (Nice) has agreed to update its guidelines on endometriosis diagnosis, surgical management, and surgical management when fertility is a priority. The decision came following a surveillance review led by NICE, which identified sufficient new evidence to support this update. This marks the first update to NICE’s endometriosis guidelines since 2017, representing a huge milestone for patients and practitioners alike. GlobalData believes that the implementation of these updated guidelines across the National Health Service (NHS) will not only improve the diagnosis and surgical management of endometriosis but will also reduce the social and economic burden of the condition.
Despite affecting nearly one in ten women in the UK alone, endometriosis still lacks proper research, funding, and disease awareness among both the medical community and the public. As a result, women wait eight years on average for a diagnosis after initial symptom onset, a figure that has not changed in a decade. This delay in diagnosis ultimately leads to disease progression and associated complications, such as chronic pelvic pain and infertility, which greatly affects the patients’ quality of life. For many women, pharmacological treatment options do not provide adequate symptomatic relief, and often result in considerable side effects, including menopause-like symptoms and decreases in bone mineral density. This consequently affects compliance and therefore invasive surgical intervention via laparoscopy is made, often repeatedly throughout the reproductive years. If the delay between symptom onset and diagnosis could be reduced, particularly using non-invasive diagnostic methods, this would substantially decrease the need for invasive surgical intervention.
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To address these issues, Emma Hardy MP and Hannah Bardell MP, chairs of the All-Party Parliamentary Group (APPG) on Endometriosis, jointly tabled an Early Day Motion during Endometriosis Action Month (March 2022) to ask for an update on NICE’s Guideline (NG 73) on Endometriosis: Diagnosis and Management. They argued that these guidelines are still disappointing many women with the condition in the UK and highlighted significant gaps within the guidelines relating to non-pharmacological pain management, endometriosis outside the pelvic cavity, and the mental health of those living with endometriosis.
In response to their request, NICE conducted a surveillance review of the 2017 guidelines to evaluate whether their recommendations align with the current research and evidence. This involved collecting feedback from topic experts in the area, gathering intelligence from stakeholders and internal teams within NICE, and conducting literature reviews of the published research and evidence.
Following the review, NICE concluded that there was sufficient new evidence to support an update to its guideline recommendations on three sections: diagnosis, surgical management, and surgical management when fertility is a priority. With respect to diagnosis, a significant amount of new evidence was found to support the use of diagnostic imaging techniques for deep endometriosis of the rectosigmoid. Indeed, endometriosis site-specific data highlighted that the sensitivity and specificity for rectosigmoid endometriosis were higher than other endometriosis types across all imaging modalities, suggesting that the use of diagnostic imaging may only be recommended for specific endometriosis types.
Additional evidence identified during the review indicated the potential use of laparoscopically guided transversus abdominis plane block (LTAP) and port-site local anesthetic infiltration (LAI), as well as the use of oxycodone for analgesia and the combination of bupivacaine and dexmedetomidine following laparoscopic surgery. There was also substantial new evidence that supported an update to the guidelines on surgical management when fertility is a priority. One study, comparing cystectomy with laser vaporization, found that laser vaporization treated endometrioma with significantly less damage to the adjacent healthy ovarian tissue than cystectomy. Intriguingly, another study found that laparoscopic surgery combined with gonadotropin-releasing hormone (GnRH) agonists improved hormone levels and pregnancy rate; this contradicts the existing NICE recommendation that states not to offer hormonal treatment to women who are trying to conceive as it does not improve spontaneous pregnancy rates.
Although the review highlighted gaps in research and evidence relating to mental wellbeing, as well as non-pharmacological pain management and endometriosis outside the pelvis, there remains insufficient new evidence to trigger an update in these topic areas. However, NICE stated it will further explore new approaches to address these unmet needs during scoping of the update.
The update to the guidelines represents a positive step forward for the endometriosis community. GlobalData expects to see increased prevalence of endometriosis in the UK over the next five years because of the increased awareness and improvements to diagnosis that these updated NICE guidelines will bring. The date for the update to commence has not been announced, but Endometriosis UK will be working closely with NICE to begin this process soon.
