Clinical diagnosis is valid — don't wait for laparoscopy to start treatment. ESHRE 2022 supports beginning empirical medical therapy on symptoms and examination alone. Average diagnostic delay is still 7–10 years; earlier suspicion and treatment shortens it.
Symptom clusters — suspect if
- Dysmenorrhoea that is progressively worsening or poorly responsive to simple analgesia.
- Deep dyspareunia — suggests deep infiltrating disease or pouch of Douglas involvement.
- Cyclical dyschezia (painful defecation) — suggests bowel-surface or rectovaginal disease.
- Chronic non-cyclic pelvic pain, bloating or fatigue, often with subfertility (present in 30–50% of women being investigated for infertility).
Medical management — stepwise
- NSAIDs (e.g. mefenamic acid or naproxen), started before pain onset where possible.
- Continuous combined hormonal contraception (skipping the pill-free interval) is commonly first-line hormonal therapy.
- Dienogest or the hormonal IUD are reasonable alternatives, the latter useful if contraception is also wanted.
- GnRH analogues are specialist-initiated and always paired with add-back hormone therapy to protect bone density.
Investigation — imaging first
Expert-performed transvaginal ultrasound detects endometriomas and deep infiltrating disease; MRI pelvis maps bowel/bladder/ureteric involvement before complex surgery. CA-125 is not recommended for diagnosis (poor specificity).
Multidisciplinary support
- Pelvic physiotherapy — pelvic floor dysfunction is common alongside endometriosis.
- Psychology — CBT and ACT are well-evidenced for the anxiety and low mood that often accompany chronic pain and diagnostic delay.
- Dietitian if GI symptoms (bloating, bowel upset) are prominent.
- Specialist endometriosis nurse or clinic for education and care coordination, where available.
Dienogest PBS authority. Dienogest requires PBS authority for confirmed endometriosis. Confirm current authority criteria and listing at pbs.gov.au before prescribing.
Safety
- Don't delay starting empirical medical therapy while waiting for a laparoscopy booking — clinical diagnosis is sufficient to act on.
- CA-125 is not a diagnostic test for endometriosis — don't order it to confirm or exclude the diagnosis.
- Any GnRH analogue must be co-prescribed with add-back hormone therapy to prevent bone loss.
Red flags / refer
- Pain not controlled after 6 months of appropriate medical therapy.
- Suspected deep infiltrating disease, or bowel/bladder/ureteric signs.
- Endometrioma on ultrasound → specialist surgical or fertility planning.
- Fertility wish → refer a fertility specialist alongside the endometriosis team early, not after.
WH-02 v1.0 · Reviewed Jun 2026 · Review Jun 2027
For health-professional use. Framework: ESHRE Endometriosis Guideline 2022, RANZCOG 2021. Excision is commonly preferred over ablation at surgery. PBS authority criteria change — verify at pbs.gov.au.
