{"paper_id":"66562fa5-3e65-4441-829f-aba7dfce2aa4","body_text":"1 Information on these guidelines\n1.1 Editors\nGerman and Austrian Societies for Obstetrics and\nGynecology (Deutsche und Österreichische Ge-\nsellschaften für Gynäkologie und Geburtshilfe),\nAssociation of the Scientific Medical Societies of\nGermany (Arbeitsgemeinschaft der wissenschaft-\nlichen medizinischen Fachgesellschaften, AWMF).\n1.2 Funding\nCompilation of the present guidelines was partly\nfinancially supported by the German Society for\nObstetrics and Gynecology and its Working Group\nGynecologic Endoscopy (Arbeitsgemeinschaft Gy-\nnäkologische Endoskopie, AGE).\n1.3 Lead professional organizations\nGerman and Austrian Societies for Obstetrics and\nGynecology (DGGG and OEGGG).\n1.4 Contact\nProf. U. Ulrich, M. D., Martin Luther Hospital, Cas-\npar-Theyss-Straße 27 – 31, 14 193 Berlin, Ger-\nmany.\n1.5 Additional information\nThe present short version is based on the full ver-\nsion of the S2k Guidelines for the Diagnosis and\nTreatment of Endometriosis, accessible via inter-\nnet as follows:\n\" http://www.awmf.org/leitlinien/\naktuelle-leitlinien.html\n\" http://www.dggg.de\n\" http://www.oeggg.at\n\" http://www.sggg.de\n\" http://leitlinien.net\n\" http://AG-Endoskopie.de\nAdditional information on the topic is available\nthrough:\n\" Endometriosis Research Foundation (Stiftung\nEndometrioseforschung,\nhttp://www.endometriose-sef.de)\n\" The Royal College of Obstetricians and Gynae-\ncologists Clinical Green-Top Guidelines for the\nInvestigation and Management of Endometrio-\nsis (http://www.rcog.org.uk/)\n\" ESHRE Guideline for the Diagnosis and Treat-\nment of Endometriosis (http://www.eshre.eu)\n\" The American College of Obstetrics and Gyne-\ncology Committee on Practice Bulletins (http://\nwww.acog.org/)\n\" Guidelines report of the present guidelines (see\nfull version).\nInterdisciplinary S2k Guidelines for the Diagnosis\nand Treatment of Endometriosis\nShort Version – AWMF Registry No. 015–045, August 2013\nInterdisziplinäre S2k-Leitlinie für die Diagnostik und Therapie der Endometriose\nKurzversion – AWMF-Register-Nummer: 015-045, August 2013\nAuthors U. Ulrich1, O. Buchweitz2,R .G r e b3, J. Keckstein4, I. von Leffern 5, P. Oppelt6, S. P. Renner7, M. Sillem8, W. Stummvoll †9,\nK.-W. Schweppe 10, for the Task Force Group “Endometriosis Guidelines” of the German and Austrian Societies\nfor Obstetrics and Gynecology\nAffiliations The affiliations are listed at the end of the article.\nBibliography\nDOI http://dx.doi.org/\n10.1055/s-0033-1350810\nGeburtsh Frauenheilk 2013; 73:\n890–898 © Georg Thieme\nVerlag KG Stuttgart · New York ·\nISSN 0016‑5751\nCorrespondence\nProf. Dr. Uwe Ulrich\nDepartment of Obstetrics and\nGynecology\nMartin Luther Hospital\nCaspar-Theyss-Straße 27–31\n14193 Berlin\nu.ulrich@mlk-berlin.de\nDGGG-Leitliniensekretariat\nProf. Dr. med.\nMatthias W. Beckmann,\nDGGG-Leitlinienbeauftragter\nFrauenklinik\nUniversitätsklinikum Erlangen\nUniversitätsstraße 21–23\n91054 Erlangen\nTel.: 0 91 31-85-3 35 07/4 40 63\nFax: 0 91 31-85-3 39 51\n890\nUlrich U et al. Interdisciplinary S2k Guidelines … Geburtsh Frauenheilk 2013; 73: 890 –898\nGebFra Science\n\n\n1.6 Responsibilities\n1.6.1 Task Force Group for these guidelines\nDirecting author\nExpert panel (Task Force Group Endometriosis Guidelines)\nOfficial representatives of the professional associations that have\nconsented\n1.6.2 Consulting\nMonika Nothacker, M. D., Berlin, Germany (Association of the\nScientific Medical Societies of Germany (Arbeitsgemeinschaft\nder wissenschaftlichen medizinischen Fachgesellschaften).\n1.7 Abbreviations used in this paper\nAFS American Fertility Society\nAGE Arbeitsgemeinschaft Gynäkologische Endoskopie der\nDGGG (Working Group Gynecologic Endoscopy DGGG)\nAGO Arbeitsgemeinschaft Gynäkologische Onkologie der\nDGGG und der Deutschen Krebsgesellschaft (Working\nGroup Gynecologic Oncology of the DGGG and the Ger-\nman Cancer Society)\nCT computed tomography\nDGGG Deutsche Gesellschaft für Gynäkologie und Geburtshilfe\n(German Society for Obstetrics and Gynecology)\nDIE deep infiltrating endometriosis\nEEL Europäische Endometriose Liga (European Endometrio-\nsis League)\nENZIAN name of a hotel in Weissensee, Carinthia (Austria)\nwhere the classification of DIE was first established by\nan SEF expert group in 2002\nGnRHa gonadotropin-releasing hormone analog\nHRT hormone replacement therapy\nICSI intracytoplasmatic sperm injection\nIUD intrauterine device\nIUI intrauterine Insemination\nIVF in-vitro fertilization\nMRI magnetic resonance imaging\nOC oral contraceptive (orales, hormonelles Antikonzepti-\nvum)\nOEGGG Österreichische Gesellschaft für Gynäkologie und Ge-\nburtshilfe (Austrian Society for Obstetrics and Gynecol-\nogy)\nrASRM (revised) American Society for Reproductive Medicine\n(-classification)\nSEF Stiftung Endometrioseforschung (Endometriosis Re-\nsearch Foundation)\nName Place\nProf. Uwe Ulrich, M. D. Berlin, Germany\nName Place\nOlaf Buchweitz, M. D. Hamburg, Germany\nRadek Chvatal, M. D. Znaim, Czech Republic\nProf. Rudy-Leon De Wilde, M. D. Oldenburg, Germany\nProf. Andreas D. Ebert, M. D., Ph.D. Berlin, Germany\nBruno Engl, M. D. Bruneck, South Tyrol\nIngo von Leffern, M. D. Hamburg, Germany\nProf. Robert Greb, M. D. Dortmund, Germany\nGülden Halis, M. D. Berlin, Germany\nDietmar Haas, M. D. Linz, Austria\nProf. Jürgen Hucke, M. D. Wuppertal, Germany\nProf. Jörg Keckstein, M. D. Villach, Austria\nProf. Michel Müller, M. D. Berne, Switzerland\nProf. Peter Oppelt, M. D. Linz, Austria\nStefan P . Renner, M. D. Erlangen, Germany\nMartin Sillem, M. D. Mannheim, Germany\nProf. Karl-Werner Schweppe, M. D. Westerstede, Germany\nWolfgang Stummvoll†, M. D. Linz, Austria\nProf. Hans-Rudolf Tinneberg, M. D. Gießen, Germany\nFrank Tuttlies, M. D. Villach, Austria\nProf. Uwe Ulrich, M. D. Berlin, Germany\nProf. Ludwig Wildt, M. D. Innsbruck, Austria\nProfessional association Name Place\nGerman Society for Obstetrics and Gynecology Prof. Ludwig Kiesel, M. D. Münster, Germany\nProf. Hans-Rudolf Tinneberg, M. D. Giessen, Germany\nGerman Society for General and Visceral Surgery Prof. Jan Langrehr, M. D. Berlin, Germany\nGerman Society for Urology Prof. Jürgen Geschwend, M. D. Munich, Germany\nGerman Society for Gynecologic Endocrinology and Reproductive\nMedicine (Working Group of the DGGG)\nProf. Ludwig Kiesel, M. D. Münster, Germany\nWorking Group Gynecologic Endoscopy (AGE/DGGG) Prof. Uwe Ulrich, M. D. Berlin, Germany\nWorking Group Gynecologic Oncology (AGO/DGGG) Prof. Uwe Ulrich, M. D. Berlin, Germany\nGerman Society for Psychosomatic Obstetrics and Gynecology Friederike Siedentopf, M. D. Berlin, Germany\nSwiss Society for Obstetrics and Gynecology Prof. Michel Müller, M. D. Berne, Switzerland\nAustrian Society for Obstetrics and Gynecology Prof. Jörg Keckstein, M. D. Villach, Austria\nProf. Peter Oppelt, M. D. Linz, Austria\nWolfgang Stummvoll†, M. D. Linz, Austria\nProf. Ludwig Wildt, M. D. Innsbruck, Austria\nCzech Society for Obstetrics and Gynecology Radek Chvatal, M. D. Znaim, Chech Republic\nEduard Kucera, M. D. Prague, Czech Republic\nEndometriosis Research Foundation (SEF) Prof. Karl-Werner Schweppe, M. D. Westerstede, Germany\nEuropean Endometriosis League (EEL) Prof. Hans-Rudolf Tinneberg, M. D. Gießen, Germany\nStefan P. Renner, M. D. Erlangen, Germany\nEndometriosis Association Germany (self-help) Dr. Heike Matuszewski Berlin, Germany\nEndometriosis Association Austria (self-help) Katrin Steinberger Vienna, Austria\n891\nUlrich U et al. Interdisciplinary S2k Guidelines … Geburtsh Frauenheilk 2013; 73: 890 –898\nGuideline\n\n\n2 Special Notes\nWhile a company ʼs brand name, or a registered trade mark, re-\nspectively, are not necessarily given in the present paper, it must\nnot be presumed that such name or mark was free.\nAs medical science is a rapidly developing field, informations and\nrecommendations given in these guidelines do represent the\nstate-of-the-art knowledge as it stands at the time of submission\nof the paper. Utmost care has been taken by the expert panel to\nextract that knowledge from the scientific literature as well as\ntheir personal experience. Having said that, the user remains\nfully liable for all applications based upon recommendations giv-\nen in the present paper.\nThe reader ʼs attention is drawn to the fact that oral contracep-\ntives (OCs) and intrauterine levonorgestrel-releasing systems\nare not specifically approved in Germany for the treatment of en-\ndometriosis. Thus, their therapeutic application for the treat-\nment of endometriosis is made off label.\nFinally, this work is fully protected. Any use that infringes the law\non copyright without written permission by the editors, authors,\nand copyright holders, respectively, is prohibited and considered\na criminal offense. No part of these guidelines may be reproduced\nin any form without the written permission of the editors and au-\nthors. This applies to photocopies, translations, microfilms, and\nto the storage, use and processing on electronic media, intranets\nand the internet.\n3 Introduction and General Comments\n3.1 Definition and epidemiology\nStatements:\na. Endometriosis – one of the most common gynecologic diseases\n– is defined as the occurence of endometrium-like cell forma-\ntions outside the uterine cavity.\nb. The cardinal symptom is chronic pelvic pain. Infertility is com-\nmon.\nThere are about 20 000 hospital admissions per year for endome-\ntriosis in Germany (Haas et al. 2012). Pathologically and histolog-\nically, endometriosis is a benign disease. However, infiltrative\ngrowth into adjacent organs is possible requiring extensive surgi-\ncal procedures.\n3.2 Etiology, pathology, and staging\nStatement:\nEtiology and pathogenesis of endometriosis are not fully under-\nstood. Therefore, a causal therapy is not known to date.\nRecommendation:\nAll staging systems known to date have their limitations. In order\nto ensure the international comparability of data, the use of the\nrASRM staging system – and in cases of deep infiltrating endo-\nmetriosis the additional use of the ENZIAN classification – is rec-\nommended.\nEndometriosis and malignancy\nStatements:\na. In rare cases, malignancy – usually ovarian cancer – may arise\nfrom endometriosis.\nb. Aside from this, the association of other, non-gynecologic ma-\nlignancies with endometriosis has been described in the litera-\nture. The clinical significance of this observation is not under-\nstood.\n4 Diagnosis and Treatment of Endometriosis\nStatements:\na. Indications for endoscopic diagnosis and treatment of endo-\nmetriosis are as follows:\n\" Chronic pelvic pain,\n\" Destruction of organs, and/or\n\" Infertility.\nb. For control of symptoms, the surgical removal of endometriotic\nlesions is considered as “gold standard” (Abbott et al. 2004, De-\nguara et al. 2012, Garry 2004).\nRecommendations:\nIn general, the diagnosis of endometriosis is to be established his-\ntologically. Hence, diagnostic laparoscopy is essential for the di-\nagnostic work-up (Walter et al. 2001).\n4.1 General comments\nSome affected women have no symptoms. Also, there is no corre-\nlation between stage of the disease and grade of symptoms.\nAsymptomatic endometriosis in a woman without infertility is\nno indication of surgical or other medical interventions (excep-\ntion: endometriosis-related hydronephrosis). Almost every\nwoman with symptomatic endometriosis suffers from dysmen-\norrhea. If this cardinal symptom is lacking, other differential diag-\nnoses are to be considered (see Guidelines for Chronic Pelvic Pain\nin Women, AWMF Registry No. 016 – 001, Sillem u. Teichmann\n2003, Siedentopf et al. 2009).\n4.2 Peritoneal endometriosis\nStatements:\na. The diagnosis of peritoneal endometriosis is made laparoscop-\nically.\nb. Treatment of choice is the laparoscopic removal of the im-\nplants.\nRecommendation:\nFollowing hormonal suppression of the ovarian function, endo-\nmetriotic implants may undergo regression. For the reduction of\nendometriosis-associated symptoms, progestins, OCs, or GnRH\nanalogs may be used in order to induce therapeutic amenorrhea\n(Abou-Setta et al. Cochrane Review 2013, Brown et al. Cochrane\nReview 2012, Allen et al. Cochrane Review 2009).\n4.3 Ovarian endometriosis (endometriomas)\nStatement:\nThe diagnosis of ovarian endometriomas is primarily made by\ntransvaginal ultrasound.\nRecommendations:\na. For primary treatment of ovarian endometriomas, the cyst\nwall should be removed surgically. Fenestration alone is con-\nsidered insufficient.\nb. Endocrine drug treatment alone is neither effective in elimi-\nnating an ovarian endometrioma (and, consequently, to re-\nplace its surgical removal) – nor in compensating for incom-\nplete surgical removal. Therefore, it is not recommended.\n892\nUlrich U et al. Interdisciplinary S2k Guidelines … Geburtsh Frauenheilk 2013; 73: 890 –898\nGebFra Science\n\n\nDifferential diagnosis\nIn ovarian endometriomas, often a typical echogenic pattern is\nfound (Hudelist et al. 2009b). However, there are also sonograph-\nically complex ovarian masses with heterogeneous appearance\nmaking it sometimes difficult to differentiate between functional\novarian cysts on the one side and dermoid cysts, kystomas, or\novarian malignant neoplasms on the other side. If a laparoscopic\napproach is scheduled in unclear ovarian findings, the DGGG S1\nGuidelines for Laparoscopic Surgery of Ovarian Tumors apply\n(AWMF Registry No. 015 – 003). Any unclear ovarian mass must\nbe clarified histologically.\nAs the CA-125 level in endometriosis patients is consistently ele-\nvated, its assessment is not recommended routinely. The same\napplies to the serum level of human epididymal protein (HE4,\nLenhard et al. 2011, Zheng and Gao 2012).\n4.4 Deep infiltrating endometriosis\nStatements:\na. Deep infiltrating endometriosis (DIE) is defined as involve-\nment of the rectovaginal septum, vaginal fornix, retroperito-\nneum (pelvic side wall, parametrium), bowel, ureters, and uri-\nnary bladder.\nb. The primary diagnosis of DIE is made clinically with rectovagi-\nnal palpation, inspection with divided specula, vaginal ultra-\nsound, and transabdominal ultrasound of the kidneys being\nmandatory.\nRecommendations:\na. For treatment, complete resection of DIE should be performed.\nNonetheless, compromises must be made as preservation of\nfertility often is imperative. Considering that the disease is be-\nnign and potentially relevant complications may occur, the ex-\ntent of resection should be thoroughly discussed and agreed\nupon with the patient.\nb. Treatment of DIE should be carried out in specialized centers\nwith a multidisciplinary approach (Ebert et al. 2013).\nc. If patients with DIE are to be managed conservatively – as well\nas pre- and postoperatively – sonographic examination of the\nkidneys is mandatory in order to avoid overlooking silent hy-\ndronephrosis. DIE-associated hydronephrosis is an absolute in-\ndication of appropriate diagnosis and treatment.\nHormone replacement therapy in patients with endometriosis\nPremenopausal patients who have undergone hysterectomy be-\ncause of endometriosis – proper indication provided – should re-\nceive a combined estrogen-progestin HRT. In postmenopause, in\nview of the fact that there is a potential risk of malignancy (see\nparagraph on endometriosis-associated malignancy), combined\nestrogen-progestin HRT – or tibolone – is recommended as well\n(Moen et al. 2010, Soliman and Hillard 2006). Nonetheless, the\nproblem of breast cancer risk has to be balanced against that –\nand an individual decision made together with the patient (see\nalso S3 Guidelines for HRT in the peri- and postmenopause,\nAWMF Registry No. 015– 062).\n4.5 Adenomyosis\nStatement:\nThe diagnosis of adenomyosis is primarily established clinically\nby vaginal ultrasonography and/or MRI. Most often, it is only the\nhistological result after hysterectomy that is proving.\nRecommendations:\na. Given completion of family planning and presence of respec-\ntive symptoms, hysterectomy can be recommended.\nb. If the patient opts for preservation of the uterus, a therapeutic\namenorrhea may be induced, or a progestin-releasing IUD in-\nserted (Garcia and Isaacson 2011).\n5 Endometriosis and Infertility\nStatements:\na. While a causal relationship has not been resolved yet, endome-\ntriosis and infertility are often associated.\nb. For the treatment of women with both endometriosis and in-\nfertility, appropriate skills and experience in infertility surgery,\nas well as cooperation with centers for reproductive medicine\nare required.\nRecommendations:\na. In women with both infertility and endometriosis, the im-\nplants should be surgically removed for the improvement of\nfertility.\nb. In cases of recurrence, assisted reproductive technologies are\nsuperior to repeated surgery in terms of pregnancy rate. In re-\npeat operations for ovarian endometriosis, the surgery-related\nreduction of ovarian reserve is to be considered.\nc. Postoperative treatment with GnRH analogs was ineffective in\nimproving spontaneous pregnancy rates and is, therefore, not\nrecommended.\nd. Any drug treatment for endmetriosis alone does not improve\nfertility and should not be applied from a reproductive-medi-\ncine perspective.\n6 Psychosomatic Aspects\nRecommendation:\nPsychosomatic aspects in the treatment of patients with endo-\nmetriosis should be considered and integrated early on.\n7 Complementary and Integrative Treatment\nApproaches\nNo statements, no recommendations.\n8 Rehabilitation, Follow-up, and Self-help\nStatement:\nAfter extensive surgery – especially for deep infiltrating endome-\ntriosis, after repeat endometriosis operations, or in patients with\nchronic pain, there often is a need for rehabilitation.\nRecommendation:\nThis need mentioned should be assessed, and measures of reha-\nbilitation, or after-care, respectively, be initiated.\n893\nUlrich U et al. Interdisciplinary S2k Guidelines … Geburtsh Frauenheilk 2013; 73: 890 –898\nGuideline\n\n\nAffiliations\n1 Klinik für Gynäkologie und Geburtshilfe, Martin-Luther-Krankenhaus, Berlin\n2 Tagesklinik Altonaer Straße, Hamburg\n3 Kinderwunschzentrum Dortmund, Dortmund\n4 Abteilung für Gynäkologie und Geburtshilfe, Landeskrankenhaus, Villach\n5 Klinik für Gynäkologie und Geburtshilfe, Albertinen-Krankenhaus, Hamburg\n6 Abteilung für Gynäkologie und Geburtshilfe, Landesfrauen- und Kinderklinik,\nLinz\n7 Frauenklinik, Universitätsklinikum Erlangen, Erlangen\n8 Praxisklinik am Rosengarten, Mannheim\n9 vormals Abteilung für Gynäkologie, Krankenhaus der Barmherzigen\nSchwestern, Linz\n10 Endometriosezentrum Ammerland, Westerstede\nReferences\n1 Abbott J, Hawe J, Hunter D et al. Laparoscopic excision of endometrio-\nsis: a randomized, placebo-controlled trial. Fertil Steril 2004; 82: 878 –\n884\n2 Abou-Setta AM, Houston B, Al-Inany HG et al. 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