{"paper_id":"088f9f0a-2362-471e-a7b0-bd7c97d1a7f1","body_text":"O R I G I N A L A R T I C L E Open Access\nMedical management of deeply infiltrating\nendometriosis - 7 year experience in a\ntertiary endometriosis centre in London\nMarianne Wild 1* , Tariq Miskry 2, Asmaa Al-Kufaishi 2, Gillian Rose 3,4 and Mary Crofton 5\nAbstract\nBackground: Deeply infiltrating endometriosis has an estimated prevalence of 1% in women of reproductive age.\nNinety percent have rectovaginal lesions but disease may also include the bowel, bladder and ureters. Current\npractice often favours minimally invasive surgical excision; however, there is increasing evidence that medical\nmanagement can be as effective as long as obstructive uropathy and bowel stenosis are excluded. Our objective\nwas to establish the proportion of women with deeply infiltrating endometriosis successfully managed with\nhormonal therapies within our tertiary endometriosis centre in West London. Secondary analysis was performed on\nanonymised data from the Trust ’s endometriosis database.\nResults: One hundred fifty-two women with deeply infiltrating endometriosis were discussed at our endometriosis\nmultidisciplinary meeting between January 2010 and December 2016. Seventy-five percent of women underwent a\ntrial of medical management. Of these, 44.7% did not require any surgical intervention during the study period, and\n7.9% were symptomatically content but required interventions to optimise their fertility prospects. Another 7.0%\nwere successfully medically managed for at least 12 months, but ultimately required surgery as their symptoms\ndeteriorated. 26.5% took combined oral contraceptives, 14.7% oral progestogens, 1.5% progestogen implant, 13.2%\nlevonorgestrel intrauterine device, 22.1% gonadotrophin-releasing hormone analogues, and 22.1% had analogues\nfor 3–6 months then stepped down to another hormonal contraceptive. All women who underwent serial imaging\ndemonstrated improvement or stable disease on MRI or ultrasound.\nConclusions: Medical treatments are generally safe, well tolerated and inexpensive. More than half (52.6%) of\nwomen were successfully managed with medical therapy to control their symptoms. This study supports the\ngrowing evidence supporting hormonal therapies in the management of deeply infiltrating endometriosis. The\nfindings may be used to counsel women on the likely success rate of medical management.\nKeywords: Endometriosis, Deeply infiltrating endometriosis, Pelvic pain, Hormonal therapy, Medical management,\nContraceptive, Progestogen, Combined oral contraceptive, Levonorgestrel-releasing intrauterine system,\nGonadotrophin-releasing hormone\nBackground\nEndometriosis is a chronic oestrogen-driven condition\ncharacterised by the presenceof ectopic endometrial glands\nand stroma outside the endometrial cavity. Deeply infiltrat-\ning endometriosis (DIE) is def ined as endometriotic tissue\nfound more than 5 mm below the peritoneal surface. It has\nan estimated prevalence of 1% in women of reproductive\nage—90% have rectovaginal lesions but disease may also\ninclude the bowel, bladder, and ureters [1].\nEvidence supporting the use of hormonal therapies in\nthe management of women with symptomatic DIE has\nbeen accumulating since the early 2000s [ 2–8]. In 2013,\na small Italian study [ 9] demonstrated a reduction in\nmean rectovaginal nodule volume in women using vari-\nous forms of medical management for over 12 months.\nDespite this, current practice favours laparoscopic surgi-\ncal excision, largely due to a belief amongst gynaeco-\nlogical surgeons that medical treatment is ineffective in\n© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0\nInternational License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and\nreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to\nthe Creative Commons license, and indicate if changes were made.\n* Correspondence: marianne.wild@nhs.net\n1Department of Obstetrics and Gynaecology, Croydon Health Services NHS\nTrust, Croydon University Hospital, 530 London Road, London CR7 7YE, UK\nFull list of author information is available at the end of the article\nGynecological SurgeryWild et al. Gynecological Surgery           (2019) 16:12 \nhttps://doi.org/10.1186/s10397-019-1065-9\n\ncomplex disease. A review article published in 2017 [ 10]\nwent as far to say: ‘It is widely agreed that severe endo-\nmetriosis, especially in symptomatic DIE with colorectal\nextension, requires surgical treatment ’. It is worth re-\nmembering that a significant number of women with\nrectovaginal disease are in fact asymptomatic, and never\nneed any treatment. To be able to manage symptomatic\ndisease with relatively simple, reversible medical treat-\nments is an attractive solution. This approach has the\nadvantage of avoiding patient morbidity associated with\ncomplex surgery, including complications such as haem-\norrhage, infection and bladder, bowel or ureteric injury.\nIt further avoids the consequences of bowel surgery\nincluding the need for temporary stoma, fistulae and\nanastomotic leaks. Bowel resection of rectovaginal endo-\nmetriosis is likely to be associated with a higher inci-\ndence of complications than resections performed for\nother diagnoses [ 11]. Although there has been a substan-\ntial shift towards more conservative surgery in recent\nyears (such as rectal shave in preference to excisional re-\nsection [ 11, 12], and nerve-sparing surgery [ 13–15]),\nthere has not been a concurrent trend towards conserva-\ntive or medical therapy. In the longer term, the inevit-\nable neurological damage sustained during radical\ndissection, causing constipation, voiding difficulties and\nsexual dysfunction may be circumvented by using med-\nical therapies first-line.\nOur objective was to determine the rate of successful\nmedical management in women with DIE within our\nendometriosis service. The Trust is accredited by the\nBritish Society for Gynaecological Endoscopy (BSGE) as\nan Endometriosis Surgical Centre. The monthly endo-\nmetriosis multidisciplinary team meeting (MDT) is\nattended by a dedicated team of gynaecological surgeons,\nradiologists, colorectal surgeon, urologist, fertility spe-\ncialist and nurse specialist.\nMethods\nWe performed a retrospective observational study of\nwomen with DIE discussed at the Imperial College\nHealthcare NHS Trust Endometriosis MDT between\nJanuary 2010 and December 2016. The Trust is based in\nWest London and is made up of two tertiary units —St\nMary’s Hospital, and Queen Charlotte ’s and Chelsea\nHospital. The project was registered and approved with\nthe Trust ’s Audit Department. Secondary analysis was\nperformed on fully anonymised data; therefore, as per\nnational and international guidelines, ethical approval\nwas not sought.\nWomen had been identified from the Endometriosis\nMDT database, and manual case note review was per-\nformed to confirm the presence of DIE. Specifically, we\nreviewed the patient ’s imaging reports within the previ-\nous 12 months to identify evidence of endometriotic\nnodules or plaques involving the rectum, bowel, bladder\nand/or ureters. Women who had undergone recent diag-\nnostic surgery (within the last 12 months) demonstrating\nDIE were also included. Women without good evidence\nof DIE, including those with ovarian endometriomas or\n‘kissing ovaries ’ alone, were excluded. The paper and\nelectronic medical records of women with DIE identified\non pelvic imaging and/or at laparoscopy were examined.\nData collected included (1) previous medical and surgical\nmanagement, (2) imaging modality and results, (3) man-\nagement plan made at the Endometriosis MDT meeting,\n(4) subsequent medical and surgical management, (5)\nnumber of appointments with the surgical team(s), (6)\nendometriosis clinic status including referral to other clin-\nical teams and (7) complications. Documented communi-\ncation and written correspondence between the patient,\nendometriosis team members and general practitioner\nwere also extensively reviewed to make an assessment of\nthe patient ’s symptoms at presentation and following\ntreatment. Follow-up of the women ’s clinical progress\ncontinued up until January 2018.\nResults\nTwo hundred three women were discussed at the Imper-\nial College Healthcare NHS Trust MDT between January\n2010 and December 2016. Fifty-one women were ex-\ncluded. Forty-one did not meet the criteria to diagnose\nDIE, and 10 case notes could not be obtained via med-\nical records. This left a total of 152 women.\nThe mean and median age of women at the time of\nMDT discussion was 37 (range 24 –57 years). Sixteen\nwomen were discussed in the endometriosis MDT meet-\ning more than once. Women included in the analysis\nwere diverse in regards to their symptoms, severity of\ndisease and previous medical and surgical managements.\n70.4% (107/152) of women had tried some form of hor-\nmonal therapy prior to referral to the endometriosis ser-\nvice, with 21.7% (33/152) trying more than one\npreparation. The most frequently used preparations were\nthe combined contraceptive pill and gonadotrophin-\nreleasing hormone (GnRH) analogues. However, 29.6%\n(45/152) women had not tried any form of medical man-\nagement in the past, even for the purposes of contracep-\ntion. 27.6% (42/152) of women had not had any form of\nsurgical intervention for endometriosis or pelvic pain in\nthe past. 50.7% of women (77/152) had one previous\nsurgical procedure and 5.3% (8/152) of women had\nundergone at least two surgical procedures. Table 1 is a\nsummary of the relevant surgical procedures women had\nundertaken prior to MDT discussion.\nSeventy-five percent (114/152) of women with DIE\nunderwent a trial of medical management. Medical man-\nagement was theoretically inappropriate in the remaining\ncases—15 women wanted to conceive, 14 declined and 9\nWild et al. Gynecological Surgery           (2019) 16:12 Page 2 of 7\n\nwere asymptomatic or postmenopausal. Seven women\ncited intolerable side effects as the reason for declining a\nfurther trial of medical management. There were no cases\nof obstructive uropathy, bowel stenosis or other medical\ncontraindications to hormonal therapies.\nTable 2 demonstrates the outcomes of women man-\naged within the endometriosis service over the 7-year\nstudy period. Out of the 114 women who accepted med-\nical management, 44.7% did not require any surgical or\nother intervention during the study period, and 7.9%\nwere symptomatically content on medical management\nbut sought to conceive within 12 months of initiating\nhormonal treatment. Of these, three women required\nsurgery to optimise their fertility prospects in prepar-\nation for oocyte retrieval and in vitro fertilisation.\nDrainage, ablation and/or excision of large (> 5 cm)\nendometriomas, freeing of the ovaries and salpingec-\ntomy/tubal clipping were performed as necessary. Six\nwomen proceeded directly to an in vitro fertilisation\ncycle. Another 7.0% were successfully medically man-\naged for at least 12 months, but ultimately chose surgery\nas their symptoms deteriorated. Therefore, 52.6% of\nwomen were successfully managed with medical therapy\nto control their symptoms.\n37.7% of women were initiated on a treatment they\nhad tried in the past. Of those successfully medically\nmanaged, 26.5% took combined oral contraceptives,\n14.7% oral progestogens, 1.5% progestogen implant,\n13.2% levonorgestrel intrauterine device and 22.1%\nGnRH analogues, and 22.1% had GnRH analogues for\nTable 1 A summary of the surgical procedures performed prior to MDT discussion\nPrevious surgery Total Laparoscopic Open\nComplex endometriosis surgery 17 7 9\nRectal shave 6\nBowel resection 7\nResection of ureteric nodule 3\nResection of bladder nodule 1\nOvarian cystectomy/drainage of endometrioma ± ablation of cyst wall 46 33 13\nOophorectomy 1 1\nDiathermy or laser to superficial disease 35 35\nDiagnostic laparoscopy 31\nMyomectomy 8 3 5\nHysterectomy ± salpingoophorectomy 3 2 1\nVideo-assisted thoracoscopic surgery (VATS) Pleurodesis for haemothorax 1\nExcision of endometriotic umbilical nodule 1\nTable 2 Outcomes of women managed within the endometriosis service over the 7-year study period\nTotal\n(%)\nCombined oral\ncontraceptives\nProgestogens–\noral\nProgestogens–\ndepo/implant\nProgestogens–\nlevonorgestrel\nreleasing IUS\nGnRH\nAnalogues\n± HRT\nGnRH Analogues 3 –6\nmonths, followed by a\ncontraceptive\nGood control of symptoms —\nno further surgery required\n51 (33.6) 14 8 1 7 8 13\nGood control of symptoms —\nwanted to conceive within 12\nmonths\n9 (5.9) 2 2 0 1 4 0\nGood control of symptoms for\nover 12 months—surgery\nultimately required\n8 (5.3) 2 0 0 1 3 2\nPoor control of symptoms —\nsurgery required\n46 (30.3) 3 3 0 2 38 0\nPoor control of symptoms —\nwanted to conceive\n15 (9.9) –––– – –\nDeclined medical\nmanagement\n14 (9.2) –––– – –\nAsymptomatic/\npostmenopausal\n9 (5.9) –––– – –\nWild et al. Gynecological Surgery           (2019) 16:12 Page 3 of 7\n\n3–6 months then stepped down to another hormonal\ncontraceptive. In the 51 women who aimed to continue\nlong-term medical management, the mean duration of\nhormonal therapy was 22 months. The maximum re-\ncorded duration of treatment was 110 months, using the\nlevonorgestrel intrauterine device.\nOf the 17 women who already had complex surgery\nfor deeply infiltrating endometriosis in the past, 11 had\nsuccessful medical management. Two of these women\nceased treatment within 12 months to try to conceive.\nThree women declined hormonal therapies, and three\nwomen had poor symptom control on medical treat-\nments and required surgery. Four women underwent\npelvic clearance and two women had repeat conservative\nsurgery performed laparoscopically. Of the 14 women\nwho accepted a trial of medical management, 7 women\nhad GnRH analogues, 6 took combined oral contracep-\ntive pills and one women opted for the levonorgestrel\nintrauterine device. All three women with poor symptom\ncontrol on medical management were using GnRH\nanalogues.\nOut of 114 women, 5 complained of bothersome side\neffects as a result of medical management. Three women\nopted for surgical management following a trial of\nGnRH analogues, despite the addition of add-back hor-\nmone replacement therapy (HRT). One woman was\nswitched to an oral progestogen and successfully contin-\nued with long-term medical management. The fifth\nwoman took GnRH analogues with add-back HRT for\n12 months but did not require further treatment as her\nsymptoms had improved.\nPelvic magnetic resonance imaging (MRI) is the pri-\nmary mode of imaging used to screen for DIE within the\nTrust. 98.6% women underwent a pelvic MRI within 12\nmonths of the MDT. 58.6% women underwent a pelvic\nultrasound within 12 months. Sixteen women who\nunderwent a trial of medical management had serial im-\naging performed during the study period. Five women\nhad demonstrated improvement in their imaging find-\nings, with a reduction in the size of endometriotic nod-\nules and/or endometriomas. Eleven women had stable\ndisease and none demonstrated progression of disease\nduring the study period.\nThe average number of visits to the endometriosis\nclinic before and after the Endometriosis MDT meeting\nwas 2.3. Table 3 demonstrates that there was no signifi-\ncant difference between women treated medically versus\nsurgically, in terms of the number requiring continued\nfollow-up, referral to other specialties of relevance, or those\ndischarged from the endometriosis clinic ( p value > 0.05\nusing N–1C h is q u a r e dt e s t ) .\nDiscussion\nOur analysis suggests that in women with DIE who find\nmedical treatment acceptable, more than half (52.6%) can\nbe treated successfully with combined contraceptives, pro-\ngestogens and/or gonadotrophin-releasing hormone ana-\nlogues. Women who have previously undergone complex\nexcisional surgery, with recurrent or intractable symp-\ntoms, can also be successfully medically managed. Our ex-\nperience illustrates that evidence from clinical trials can\nbe applied to clinical practice. It supplements the growing\nevidence in support of hormonal therapies as a valid,\nlong-term option in the management of DIE.\nMedical treatments are generally safe, effective and in-\nexpensive. Side effects are uncommon, reversible and\nwell tolerated in the majority of women. If side effects\nare troublesome, a change in preparation can often be\nconsidered. GnRH analogues can have more severe\nhypoestrogenic side effects, including implications for\nbone density in the long term. In our patient group,\nGnRH analogues were most often used in the short term\nfor relatively rapid control of pain and induction of\namenorrhoea, before introducing another hormonal\ntreatment such as the levonorgestrel IUS. A smaller\nnumber of older women remain on long-term downreg-\nulation with two yearly monitoring of their bone density.\nTo address the impact on bone density and menopausal\nsymptoms, we typically offer hormonal add-back therapy\nto coincide with commencement of GnRH analogues, as\nper current European guidance [ 16].\nImprovements in diagnostic imaging mean that the\ndiagnosis of DIE can be made in the absence of laparos-\ncopy. Furthermore, screening for ureteric stenosis,\nhydronephrosis and bowel stenosis can be performed\nconfidently by specialist ultrasonographers or by\nTable 3 Endometriosis clinic status —comparison of women treated medically and surgically\nClinic status Medical management Surgical management p value*\nDischarged from the endometriosis clinic 35 42 0.58\nReferred onwards to fertility team 9 16 0.20\nReferred onwards to chronic pain team 1 1 –\nReferred onwards to colorectal team 1 0 –\nUnder follow-up 20 13 0.09\nLost to follow-up 2 3 –\n*Determined by N –1 Chi squared test. The results are not significant at p < 0.05\nWild et al. Gynecological Surgery           (2019) 16:12 Page 4 of 7\n\nmagnetic resonance imaging [ 17]. The need for laparos-\ncopy in the assessment of DIE is therefore reduced, and\nwomen can be counselled regarding the pros and cons\nof conservative, medical and surgical managements.\nThe ideal drug to treat DIE should downregulate pro-\nliferation, preclude invasion and encourage apoptosis by\nacting on the hormonal and immunologic environment\n[18]. Progestogens and combined oral contraceptives\nhave already been demonstrated to decrease the dens-\nities of sympathetic, parasympathetic and sensory nerve\nfibres in DIE [ 19].\nSeveral systematic reviews [ 20–22] have directly com-\npared medical treatments with surgery in the manage-\nment of endometriosis, but the literature is much\nscantier when focussing on DIE. A prospective clinical\ntrial [ 9] included 79 women with rectovaginal nodules\ninfiltrating at least the muscularis propria of the rectum\nwho received one of the following: norethisterone acet-\nate, triptorelin and tibolone, norethisterone acetate and\nletrozole, desogestrel and sequential oral contraceptive\npill. When compared with baseline values, the volume of\nthe nodules decreased at 6 months ( p < 0.001) and 12\nmonths of treatment ( p < 0.001). After 12 months of\ntreatment, the mean volume of rectovaginal nodules de-\ncreased in all study groups. The effectiveness of the\nlevonorgestrel-releasing intrauterine system has also\nbeen studied for the management of rectovaginal endo-\nmetriosis. Fedele et al. [ 3] demonstrated a significant im-\nprovement in dysmenorrhoea, pelvic pain, deep\ndyspareunia and size of endometriotic nodules following\n12-month treatment with the levonorgestrel-releasing\nintrauterine system. A small proportion of nodules will\nincrease in volume, and women should be informed of\nthis [ 6, 9, 23].\nA randomised control trial [ 2] also demonstrated a\nlack of progression of existing endometriomas, and in-\nhibition of development of new endometriomas with\noral progestogens and the combined oral contraceptive\npill. Studies looking at the combined contraceptive pill,\ngonadotrophin-releasing hormonal agonists and dieno-\ngest in the management of bladder endometriosis have\nalso been promising, with complete or near-complete re-\ngression of bladder nodules [ 4, 24].\nPatient satisfaction rates and quality of life are similar\nin women with endometriotic lesions treated medically\nversus treatment by laparoscopic excision [ 25, 26]. All\nhormonal treatments have been proven to be effective in\nthe treatment of dysmenorrhoea, pelvic pain, dyspar-\neunia and gastrointestinal symptoms associated with\nDIE [ 3, 23, 27–30]. Unfortunately, early symptom recur-\nrence is common following treatment cessation, and\ntherefore short-term treatment is unlikely to be benefi-\ncial [ 7, 30]. Recurrence following laparoscopic excision\nof rectovaginal endometriosis is also well documented,\nand estimated to be between 5 and 25% [ 31]. Repeated\nsurgery for DIE becomes increasingly challenging due to\nloss of normal tissue planes. The ideal scenario would be\nfor women to be managed medically during their repro-\nductive years, and opt for pelvic clearance once their fam-\nily is complete, if medical management is no longer\nfeasible. It is our opinion that any strategy that can suc-\ncessfully reduce the need for surgery should be embraced.\nStrengths and limitations\nWomen in this study were identified from the Trust ’s\nEndometriosis MDT Database. We are aware that some\nwomen with DIE were not discussed with the multidis-\nciplinary team following review in the endometriosis\nclinic. These women were managed with hormonal ther-\napies and have remained stable on treatment, therefore\nwould not usually necessitate MDT discussion. It is our\nnormal practice for a woman with DIE being considered\nfor surgical management to be discussed in the MDT\nmeeting. Consequently, the proportion of women with\nDIE successfully medically managed within the Trust is\nlikely to be higher than described.\nThe significance of bias caused by loss to follow-up is\nlikely to be minimal, and analysis was performed on an\nintention to treat basis. Only seven women did not\ncomplete follow-up with the endometriosis service; two of\nwhom had started medical management. Both women\nwere reviewed 6 months after initiating hormonal treat-\nment and were symptomatically content. Out of the\nremaining women lost to follow-up, three were recom-\nmended to undergo surgery and had a high chance of re-\nquiring bowel resection. Two women were asymptomatic\nat presentation and had been counselled towards conser-\nvative management. Without a national hospital records\nsystem, it is difficult to assess the probability, or impact of\nwomen seeking treatment in other units.\nAn accepted limitation of our study is the retrospect-\nive, observational design and reliance on accurate docu-\nmentation by clinicians involved in the patient ’s care.\nPatient heterogeneity in terms of demographics, re-\nported symptoms, disease severity and previous treat-\nments is high. It is difficult to account for the impact of\npotential confounders, given the variety and diversity of\nvariables. For example, there was inconsistent documen-\ntation of complementary treatments, such as exclusion\ndiets, which may have affected symptomatology. A pro-\nspective study using a patient questionnaire and vali-\ndated tools to assess symptoms and quality of life could\naddress this issue.\nConclusions\nThe management of women with endometriosis should\ncontinue to be based on a variety of factors, such as the\nwomen’s symptoms, severity of disease, impact on\nWild et al. Gynecological Surgery           (2019) 16:12 Page 5 of 7\n\nquality of life, fertility status and taking in to account\nprevious treatments and their outcomes. Women with\nDIE should be managed as part of a multidisciplinary\nteam in an endometriosis centre [ 32].\nThe results of this study add further support to the\nmedical management of women with DIE. Women\nshould be informed that medical management can be ef-\nfective in managing their symptoms and disease, and has\nthe advantage of avoiding the risks associated with com-\nplex surgery. Given that nerve-sparing surgeries are still\nperformed by the minority of endometriosis surgeons,\nthe incidence of neurological trauma causing constipa-\ntion, voiding difficulties and sexual dysfunction may be\nreduced. Furthermore, hormonal therapies are generally\nsafe, well tolerated and inexpensive.\nResearch recommendations\nIn the absence of the ability to perform a randomised\ncontrolled trial with long-term follow-up, more high\nquality prospective cohort studies should be designed.\nIdeally, these would investigate the clinical and radio-\nlogical progress of women with DIE treated conserva-\ntively and with various hormonal therapies. Patient\nsatisfaction and quality of life could be assessed by a pa-\ntient questionnaire using validated tools. The British So-\nciety for Gynaecological Endoscopy currently holds a\ndatabase of women with DIE treated surgically in their\ncentres—we see no reason why a similar database for\nwomen managed medically could not be constructed,\nmaintained and analysed in a similar fashion.\nAbbreviations\nDIE: Deeply infiltrating endometriosis; MDT: Multidisciplinary team;\nGnRH: Gonadotrophin-releasing hormone; HRT: Hormone replacement therapy\nAcknowledgements\nThe authors would like to thank Nishy Munisami, Shosh Krasner-Macleod,\nNatalie Davies and Gabriella Yongue for their contribution towards data ac-\nquisition. We would also like to thank all members of the endometriosis\nmultidisciplinary team who contributed to the clinical management of\nwomen included in this study.\nAuthors’ contributions\nTM, AA and MW were responsible for the conception and design of this\nstudy. MW and AA were responsible for data acquisition. MW was\nresponsible for data analysis. MW, TM, GR and MC were responsible for data\ninterpretation. MW drafted the manuscript. MW, TM, AA, GR and MC all\ncritically revised the manuscript and gave final approval for publication.\nFunding\nNone.\nAvailability of data and materials\nThe datasets generated and analysed during the current study are not publicly\navailable as they contain information that could compromise patient confidentiality.\nThey are available from the corresponding author on reasonable request.\nEthics approval\nAccording to National Research Ethics Service (NRES) standards, ethics\napproval was not necessary due to the retrospective, observational nature of\nthe study. Secondary analysis was performed on fully anonymised data\ncollected for the purposes of departmental audit and service evaluation.\nConsent for publication\nNot applicable.\nCompeting interests\nThe authors declare that they have no competing interests.\nAuthor details\n1Department of Obstetrics and Gynaecology, Croydon Health Services NHS\nTrust, Croydon University Hospital, 530 London Road, London CR7 7YE, UK.\n2Department of Obstetrics and Gynaecology, Imperial College Healthcare\nNHS Trust, St Mary ’s Hospital, Praed Street, London W2 1NY, UK.\n3Department of Obstetrics and Gynaecology, Imperial College Healthcare\nNHS Trust, Queen Charlotte ’s and Chelsea Hospital, Du Cane Road, London\nW12 0HS, UK. 4Imperial College London, Faculty of Medicine, South\nKensington Campus, London SW7 2AZ, UK. 5Department of Radiology,\nImperial College Healthcare NHS Trust, St Mary ’s Hospital, Praed Street,\nLondon W2 1NY, UK.\nReceived: 30 May 2019 Accepted: 31 October 2019\nReferences\n1. 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A prospective pilot study.\nGynecol Obstet Fertil 43(9):575–581. https://doi.org/10.1016/j.gyobfe.2015.07.001\n30. Ferrero S, Camerini G, Seracchioli R, R agni N, Venturini PL, Remorgida V (2009)\nLetrozole combined with norethisterone acetate compared with norethisterone\nacetate alone in the treatment of pain symptoms caused by endometriosis. Hum\nReprod 24(12):3033–3041. https://doi.org/10.1093/humrep/dep302\n31. Meuleman C, Tomassetti C, D'Hoore A et al (2011) Surgical treatment of\ndeeply infiltrating endometriosis with colorectal involvement. Hum Reprod\nUpdate 17(3):311 –326. https://doi.org/10.1093/humupd/dmq057\n32. Kuznetsov L, Dworzynski K, Davies M, Overton C (2017) Diagnosis and\nmanagement of endometriosis: summary of NICE guidance. Bmj 358:j3935.\nhttps://doi.org/10.1136/bmj.j3935\nPublisher’sN o t e\nSpringer Nature remains neutral with regard to jurisdictional claims in\npublished maps and institutional affiliations.\nWild et al. 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