{"paper_id":"d7ab3a25-582e-436a-84e5-4a58e985659c","body_text":"GUIDELINES\nDiagnosis and management of endometriosis: summary of updated\nNICE guidance\nSharangini Rajesh, 1 Agnesa Mehmeti, 1 Thomas Smith-Walker,2 Bryony Kendall3, on behalf of the guideline\ncommittee\nWhat you need to know\n• A positive history in a first degree relative increases\nthe likelihood of developing endometriosis\n• Do not exclude the possibility of endometriosis if\ntransvaginal ultrasound scan is normal and history\nis suggestive\n• Both transvaginal ultrasound and pelvic magnetic\nresonance imaging should be considered for\ndiagnosis and assessment of the extent of deep\nendometriosis\nEndometriosis is a chronic condition where\nendometrium-like tissue grows outside the uterus,\nmost commonly within the pelvis, and on organs such\nas ovaries, bladder, and bowel. In the UK, about one\nin 10 women of reproductive age (from puberty to\nmenopause) has endometriosis.1\nThe condition is associated with varied clinical\nsymptoms, including chronic pain in the lower back\nand pelvis, pain while menstruating, having sex,\npassing urine or stool, and infertility. Some women\nwith endometriosis may not experience any\nsymptoms, but for others it can have a substantial\nimpact on their quality of life. In the UK, people with\nsuspected endometriosis wait an average of eight\nyears for a diagnosis.2 A prolonged time to diagnosis\nmay lead to delay in appropriate management,\nmonitoring, and disease progression.\nThe National Institute for Health and Care Excellence\n(NICE) guideline covering diagnosis and management\nof endometriosis was first published in September\n2017. A topic update related to management of fertility\nas a priority was published in April 2024.3 This article\nsummarises recently updated recommendations,\nspecifically focusing on factors associated with time\nto diagnosis, including imaging, for those working\nin primary care.\nRecommendations from this topic are for women and\npeople with suspected or confirmed endometriosis,\ntheir families, and carers. Trans men and non-binary\npeople also experience endometriosis. Therefore, this\npaper refers to “women” and “people” to reflect a\nrange of identities.\nRecommendations\nNICE recommendations are based on systematic\nreviews of best available evidence and explicit\nconsideration of cost effectiveness. When minimal\nevidence is available, recommendations are based\non the guideline development group’s (GC’s)\nexperience and opinion of what constitutes good\npractice. Evidence levels for the recommendations\nare given in italics in square brackets.\nGRADE Working Group grades of evidence\n• High certainty—we are very confident that the true\neffect lies close to that of the estimate of the effect\n• Moderate certainty—we are moderately confident in\nthe effect estimate: the true effect is likely to be close\nto the estimate of the effect, but there is a possibility\nthat it is substantially different\n• Low certainty—our confidence in the effect estimate\nis limited: the true effect may be substantially\ndifferent from the estimate of the effect\n• Very low certainty—we have very little confidence in\nthe effect estimate: the true effect is likely to be\nsubstantially different from the estimate of effect\nHistory\nThis is a new recommendation. When assessing a\nperson with signs and symptoms of endometriosis,\nthe likelihood of developing endometriosis is higher\nif there is a history of the condition in a first degree\nrelative.\n• Ask if any first degree relatives have a history of\nendometriosis, as this increases the likelihood of\nendometriosis.\n[Recommendations based on the GC’s experience]\nUltrasound\nThe updated recommendations considered an\nevidence review from 20 studies that assessed\ndiagnostics of endometriosis, which showed\ntransvaginal ultrasound scan had moderate to high\nsensitivity (70% to 100%, very low to high quality of\nevidence) and high specificity (94% to 100%,\nmoderate to high quality of evidence) for detection\nof deep endometriosis across a range of sites,\nincluding bowel, bladder, ureter, and ovaries\n(including endometrioma) (\ntable 1). Although\nsuperficial endometriosis is the most common type\nof endometriosis, this subtype was not included in\nthe recommendation as it is difficult to diagnose with\ntransvaginal ultrasound or any other imaging tests\naccurately.\n1the bmj | BMJ 2025;388:q2782 | doi: 10.1136/bmj.q2782\nPRACTICE\n1 National Institute for Health and Care\nExcellence, Manchester, UK\n2 Royal Cornwall Hospital, Truro\n3 NHS Cheshire and Merseyside,\nLiverpool\nCorrespondence to S Rajesh\nsharangini.rajesh@nice.org.uk\nCite this as:\nBMJ 2025;388:q2782\nhttp://doi.org/10.1136/bmj.q2782\nPublished: 31 January 2025\nProtected by copyright, including for uses related to text and data mining, AI training, and similar technologies. \n. by guest on 21 May 2026 https://www.bmj.com/Downloaded from 31 January 2025. 10.1136/bmj.q2782 on BMJ: first published as \n\nTable 1 | Types of endometriosis 4 5\nSigns and symptomsDefinitionType of endometriosis\n• Chronic pelvic pain\n• Period related pain (dysmenorrhoea) affecting daily activities\nand quality of life\n• Deep pain during or after sexual intercourse\n• Period related or cyclical gastrointestinal symptoms, in\nparticular, painful bowel movements\n• Period related or cyclical urinary symptoms, in particular, blood\nin the urine or pain passing urine\n• Infertility in association with one or more of the above\nShallow lesion along the peritoneum, the membrane that lines\nthe abdominal cavity, and is found in the recto-vaginal septum,\nbladder, and bowel\nSuperficial endometriosis\nA nodule at least 5 mm below the peritoneumDeep endometriosis\nEndometriosis in the pelvisPelvic endometriosis\nCysts on the ovariesEndometrioma\nSigns and symptoms consistent with system affected. For\nexample, painful rectal bleeding, haematuria, cyclical scar\nswelling and pain, cyclical shoulder pain, cyclical cough,\ncatamenial pneumothorax\nEndometriosis found in other parts of the body, eg, abdomen,\nthorax, central nervous system\nEndometriosis outside the pelvic cavity\nThe strength of the recommendations related to performing\ntransvaginal ultrasound scan in primary care has been upgraded\nfrom a weak “consider” recommendation in the previous guideline\nto a strong “offer” recommendation. Although the sensitivity and\nspecificity are operator dependent, most non-specialist\nsonographers would be able to identify ovarian endometriomas,\nand possibly cases of deep endometriosis. Furthermore, an early\ntransvaginal ultrasound scan may rule out other pathology such as\nfibroids or malignancy.\nWhen a patient declines transvaginal ultrasound or it is otherwise\nnot suitable, transabdominal scan is an alternative. In one\nprospective cohort study of 40 women with suspected endometriosis,\ntransabdominal ultrasound showed high sensitivity (91%, low\nquality evidence) and moderate specificity (75%, very low quality\nevidence) in detection of deep endometriosis in the ovaries. 6\nEvidence from the same study showed that transabdominal\nultrasound to identify deep endometriosis in the uterosacral\nligaments showed low sensitivity (25%, low quality evidence) and\nhigh specificity (97%, low quality evidence).\n• Offer a transvaginal ultrasound scan to all women or people with\nsuspected endometriosis, even if pelvic or abdominal\nexamination is normal, to:\n‐ Identify ovarian endometriomas and deep endometriosis,\nincluding that involving the bowel, bladder, or ureter\n‐ Identify or rule out other pathology which may be causing\nsymptoms\n‐ Guide management options and enable referral to an\nappropriate service, depending on the ultrasound findings.\n• This ultrasound scan should be organised by the person’s general\npractice.\n[Recommendations based on very low to high certainty diagnostic\nevidence]\n• If a transvaginal ultrasound scan is declined or not suitable for\nthe person, consider a transabdominal ultrasound scan of the\npelvis.\n[Recommendations based on the GC’s experience]\nReferral criteria\nThese updated recommendations for referral criteria to secondary\ncare services were based on the guideline committee’s experience\nonly, and were made following consensus.\nSuperficial or microscopic endometriosis will not be identified by\nultrasound scan in all cases, and diagnostic accuracy of ultrasound\nis operator dependent. Therefore, do not exclude endometriosis if\nan ultrasound scan is negative and there is clinical suspicion, and\nrefer for further investigations even after a normal scan.\nThe recommendation related to referring to secondary care\ngynaecology services was strengthened from “consider” to “offer”\nreferral, as women or people with suspected or confirmed\nendometriosis meeting criteria will need referral by general practice\nfor further investigations and management. The recommendation\nrelated to referring to tertiary specialist endometriosis services\ndirectly was amended to include suspected or confirmed\nendometrioma as one of the criteria, in addition to deep\nendometriosis. Endometriomas are often associated with deep or\nsevere endometriosis, and their management can be particularly\ncomplicated, especially if fertility is a consideration. For young\nwomen or people (aged 17 and under) with suspected or confirmed\nendometriosis, the strength of the recommendation was upgraded\nfrom “consider” in previous guidelines to “refer” in the updated\none.\nDuring assessment in primary care, people presenting with pain\nand symptoms of endometriosis should receive treatment with\nanalgesics, neuromodulators, neuropathic pain treatments, or\nhormonal treatment, as appropriate, while further investigations\nor referrals are underway.3\n• Do not exclude the possibility of endometriosis if the abdominal\nor pelvic examination and ultrasound scan are normal, and\nrecognise that referral may still be necessary even with a normal\nscan.\n[Recommendation based on the GC’s experience]\n• Refer women or people with symptoms of, or confirmed,\nendometriosis to a gynaecology service (see the recommendation\non gynaecology services) for further investigation and\nmanagement if:\n‐ Initial treatment is not effective, is not tolerated, or is\ncontraindicated, or\n‐ They have symptoms of endometriosis which have a\ndetrimental impact on activities of daily living, or\n‐ They have persistent or recurrent symptoms of endometriosis,\nor\n‐ They have pelvic signs of endometriosis, but deep\nendometriosis is not suspected.\nthe \nbmj | BMJ 2025;388:q2782 | doi: 10.1136/bmj.q27822\nPRACTICE\nProtected by copyright, including for uses related to text and data mining, AI training, and similar technologies. \n. by guest on 21 May 2026 https://www.bmj.com/Downloaded from 31 January 2025. 10.1136/bmj.q2782 on BMJ: first published as \n\n[Recommendation based on the GC’s experience]\n• Refer women or people to a specialist endometriosis service if\nthey have suspected or confirmed:\n‐ Endometrioma, or\n‐ Deep endometriosis, including that involving the bowel,\nbladder, or ureter, or\n‐ Endometriosis outside the pelvic cavity.\n[Recommendation based on the GC’s experience]\n• Refer young women or people (aged 17 and under) with suspected\nor confirmed endometriosis to a paediatric and adolescent\ngynaecology service, or specialist endometriosis service\n(endometriosis centre) for further investigation and management.\n[Recommendation based on the GC’s experience]\nPelvic magnetic resonance imaging (MRI) scan\nCurrently, ultrasound is the primary investigation for diagnosis,\nand MRI is used for diagnosis and assessment of the extent of deep\nendometriosis and to guide treatment decisions. In these updated\nrecommendations, both pelvic MRI and transvaginal ultrasound\nperformed and interpreted by specialists in secondary care,\nincluding sonographers, should now be considered for the diagnosis\nand assessment of the extent of deep endometriosis.\nAn evidence review of 10 new studies was undertaken, which\nshowed that diagnostic ability of MRI ranged from low to high\nsensitivity (39% to 100%, very low to moderate quality evidence)\nand moderate to high specificity (80% to 100%, very low to high\nquality evidence) for diagnosing deep endometriosis in various\nsites, including ovaries, vagina, rectosigmoid, rectovaginal septum,\nuterosacral ligaments, and bladder. Based on the evidence review\nfor transvaginal ultrasound scan, when performed in the secondary\ncare setting it could also be used for the diagnosis of deep\nendometriosis.\n• Consider specialist transvaginal ultrasound scan or pelvic MRI\nscan to diagnose deep endometriosis and assess its extent.\n[Recommendations based on very low to high certainty diagnostic\nevidence]\n• Ensure that specialist transvaginal ultrasound scans and pelvic\nMRI scans are planned and interpreted by a healthcare\nprofessional with specialist expertise in gynaecological imaging.\n[Recommendation based on the GC’s experience]\nImplementation\nThe updated recommendation on ultrasound will likely lead to\nincreased use of transvaginal ultrasound offered in primary care;\nhowever, this may reduce the need for a transvaginal ultrasound\nscan after referral to gynaecology services for some. Additional\ntraining of sonographers will be required to enhance sonographers’\ncompetencies in detecting features associated with endometriosis.\nReferral recommendations that have been upgraded to“refer” from\n“consider referring” are likely to lead to more people being referred\nto secondary and tertiary care services. However, earlier referral of\npeople subsequently diagnosed with endometriosis is likely to lead\nto treatment being started earlier, and may lead to a reduction in\nend organ damage owing to the disease. Although a cost\neffectiveness analysis has not been formally performed, the\nguideline committee thought earlier referral may lead to a\nsubsequent decrease in cost of overall treatment.\nGuidelines into practice\n• How do you assess a person with suspected endometriosis?\n• What factors do you use to decide if a patient needs referral to\ngynaecology or a specialist endometriosis service?\nFurther information on the guidance\nThis guidance was developed by NICE in accordance with NICE guideline\nmethodology (www.nice.org.uk/media/default/about/what-we-do/our-\nprogrammes/developing-nice-guidelines-the-manual.pdf\n). A guideline\ncommittee (GC) was established by NICE, which incorporated an\nindependent chair, a topic adviser (consultant in obstetrics and\ngynaecology), and healthcare and allied healthcare professionals (one\nclinical nurse specialist, one consultant gynaecologist, one consultant\nsurgeon, one consultant clinical psychologist, one GP with an interest in\nmaternity care, one consultant obstetrician and gynaecologist, and one\npharmacist) and three lay members. The guideline is available at\nhttps://www.nice.org.uk/guidance/ng73\n. The GC identified relevant\nreview questions and collected and appraised clinical and cost\neffectiveness evidence. Quality ratings of the evidence were based on\nGRADE methodology (\nwww.gradeworkinggroup.org). These relate to the\nquality of the available evidence for assessed outcomes rather than the\nquality of the study. The GC agreed recommendations for clinical practice\nbased on the available evidence or, when evidence was not found, based\non their experience and opinion using informal consensus methods. The\ndraft of the guideline went through a rigorous reviewing process, in which\nstakeholder organisations were invited to comment; the GC took all\ncomments into consideration when producing the final version of the\nguideline. NICE will conduct regular reviews after publication of the\nguidance, to determine whether the evidence base has progressed\nsignificantly enough to alter the current guideline recommendations and\nrequire an update.\nHow patients were involved in the creation of this article\nAnna Cooper, Emma Cox, and Sunaina Nechel-Maher are lay members\nof the guideline committee and contributed to the formulation of the\nrecommendations summarised in this article. All were involved in the\ndevelopment and reviewing of this article, to ensure lay and patient\nperspectives were considered and included.\n3the \nbmj | BMJ 2025;388:q2782 | doi: 10.1136/bmj.q2782\nPRACTICE\nProtected by copyright, including for uses related to text and data mining, AI training, and similar technologies. \n. by guest on 21 May 2026 https://www.bmj.com/Downloaded from 31 January 2025. 10.1136/bmj.q2782 on BMJ: first published as \n\nThe full version of this guideline is available at https://www.nice.org.uk/guidance/ng73.\nFunding: No authors received specific funding to write this summary.\nCompeting interests: We declared the following interests based on NICE’s policy on conflicts of interests\n(https://www.nice.org.uk/Media/Default/About/Who-we-are/Policies-and-procedures/declaration-of-\ninterests-policy.pdf):\nThe guideline authors’ full statements can be viewed at https://www.nice.org.uk/guidance/ng73.\nContributorship and the guarantor: All four authors confirm that they meet all four authorship criteria\nin the ICMJE Uniform requirements. SR is the guarantor for this article. The views expressed in this\npublication are those of the authors and not necessarily those of NICE.\nProvenance and peer review: commissioned; not externally peer reviewed.\nthe \nbmj | BMJ 2025;388:q2782 | doi: 10.1136/bmj.q27824\nPRACTICE\nProtected by copyright, including for uses related to text and data mining, AI training, and similar technologies. \n. by guest on 21 May 2026 https://www.bmj.com/Downloaded from 31 January 2025. 10.1136/bmj.q2782 on BMJ: first published as \n\nThe members of the Guideline Committee were (shown alphabetically): Alena Chong, Anna Cooper,\nAshifa Trivedi, Bryony Kendall, Chimwemwe Kalumbi, Christian Becker, Claudia Tye, Emma Cox, Emma\nEvans, Lucky Saraswat, Sarah Fishburn, Sunaina Nechel-Maher, Thomas Smith Walker.\nThe members of the NICE technical team were (shown alphabetically): Agnesa Mehmeti (technical\nanalyst), Clifford Middleton (quality and engagement manager), Hayley Jones (project manager), Hilary\nEadon (topic lead till July 2024), Maija Kallioinen (topic lead from July 2024), Paul Jacklin (health\neconomics adviser), Sharangini Rajesh (senior technical analyst), Stephanie Arnold (senior information\nspecialist).\n1 Royal College of Nursing. Endometriosis fact sheet.\n2 Endometriosis UK. Diagnosis survey. 2023.https://www.endometriosis-uk.org/diagnosis-survey-\n2023\n3 National Institute for Health and Care Excellence. Endometriosis: diagnosis and management\n(NICE guideline NG73). 2017. https://www.nice.org.uk/guidance/ng73\n4 Endometriosis UK. What is endometriosis?https://www.endometriosis-uk.org/what-endometriosis\n5 Endometriosis. Guideline of European Society of Human Reproduction and Embryology.\nhttps://academic.oup.com/hropen/article/2022/2/hoac009/6537540#google_vignette\n6 Puri S\n, Gupta A, Sandhu GS, etal. Comparison between ultrasonography and magnetic resonance\nimaging in endometriosis: a prospective study in a tertiary hospital . JSAFOG 2022;14:-90.\nhttps://www.jsafog.com/doi/JSAFOG/pdf/10.5005/jp-journals-10006-2011.\n5the bmj | BMJ 2025;388:q2782 | doi: 10.1136/bmj.q2782\nPRACTICE\nProtected by copyright, including for uses related to text and data mining, AI training, and similar technologies. \n. by guest on 21 May 2026 https://www.bmj.com/Downloaded from 31 January 2025. 10.1136/bmj.q2782 on BMJ: first published as","source_license":"public-domain-us","license_restricted":false}