Quality statement 1: Presentation with suspected endometriosis

Quality statement

Women presenting with suspected endometriosis have an abdominal and, if appropriate, a pelvic examination.

Rationale

By performing an abdominal and, if appropriate, a pelvic examination when a woman first presents with symptoms of endometriosis, delays in diagnosis and treatment can be reduced. A physical examination of the abdomen, and the pelvis if appropriate, can identify signs of endometriosis such as abdominal or pelvic masses, reduced organ mobility or enlargement, points of tenderness, or visible vaginal endometriotic lesions. This enables the healthcare professional to consider a working diagnosis of endometriosis and begin a treatment plan.

Quality measures

Structure

a) Evidence of local arrangements to identify women with signs and symptoms of endometriosis.

Data source: Local data collection, for example training records on endometriosis for healthcare professionals and audits of healthcare records.

b) Evidence of protocols detailing symptoms of endometriosis and the need for abdominal and pelvic examination when this is suspected.

Data source: Local data collection, for example local clinical protocols.

Process

a) Proportion of women who present to healthcare professionals with symptoms or signs suggesting endometriosis who have an abdominal and pelvic examination.

Numerator – the number in the denominator who have an abdominal and a pelvic examination.

Denominator – number of women presenting with symptoms or signs suggesting endometriosis for whom a pelvic examination is appropriate.

Data source: Local data collection, for example audits of GP, practice nurse, sexual health clinic, school health service or emergency department records.

b) Proportion of women who present to healthcare professionals with symptoms or signs suggesting endometriosis for whom a pelvic examination would not be appropriate who have an abdominal examination.

Numerator – the number in the denominator who have an abdominal examination.

Denominator – the number of women presenting with symptoms or signs suggesting endometriosis for whom a pelvic examination would not be appropriate.

Data source: Local data collection, for example audits of GP, practice nurse, sexual health clinic, school health service or emergency department records.

Outcome

a) Number of working diagnoses of endometriosis following initial presentation.

Data source: Local data collection, for example audits of GP records.

b) Time from initial presentation with symptoms or signs of endometriosis to diagnosis.

Data source: Local data collection, for example audits of GP and gynaecology services records.

What the quality statement means for different audiences

Service providers (such as GP practices, school health services, sexual health clinics, and emergency departments) ensure that staff are aware of the symptoms and signs of endometriosis and that facilities are in place for women presenting with a symptom or sign of endometriosis to have a physical examination. They ensure that staff know that a pelvic and abdominal examination should be carried out if appropriate. They should ensure that staff are aware that a pelvic examination may not be suitable or appropriate for some groups, for example women with learning disabilities, very young women and women who have never been sexually active, and that these groups should have an abdominal examination.

Healthcare professionals (such as GPs, practice nurses, school nurses, sexual health nurses and emergency department practitioners) consider endometriosis as a possible diagnosis when women present with a symptom or sign that suggests endometriosis. They carry out an abdominal and pelvic examination, if appropriate, to exclude other possible causes as soon as possible, either when the woman initially presents or a short time afterwards. They are aware that a pelvic examination may not be suitable or appropriate for some groups, for example women with learning disabilities, very young women and women who have never been sexually active, and they carry out abdominal examination for these groups. They are aware that the possibility of endometriosis should not be ruled out if the examination findings are normal.

Commissioners (such as NHS England, clinical commissioning groups and local authorities) ensure that they commission services that raise awareness of endometriosis among staff and have clinical protocols in place for detailing symptoms and signs of endometriosis and the need for different types of examination, depending on the woman's circumstances, when endometriosis is suspected.

Women with symptoms or signs of endometriosis (such as chronic pelvic pain, severe period-related pain or deep pain during or after sexual intercourse) have an examination of their abdomen, and of their pelvis if this is appropriate, the first time they visit a healthcare professional to discuss these symptoms or signs, or shortly afterwards if they prefer. This examination can help to rule out other possible conditions and means that treatment for endometriosis can be started quickly.

Source guidance

Endometriosis: diagnosis and management (2017) NICE guideline NG73, recommendations 1.3.3 and 1.3.4

Definitions of terms used in this quality statement

Suspected endometriosis

Suspect endometriosis in women (including young women aged under 17 years) presenting with 1 or more of the following symptoms or signs:

  • chronic pelvic pain

  • period-related pain (dysmenorrhoea) affecting daily activities and quality of life

  • deep pain during or after sexual intercourse

  • period-related or cyclical gastrointestinal symptoms, in particular, painful bowel movements

  • period-related or cyclical urinary symptoms, in particular, blood in the urine or pain passing urine

  • infertility in association with 1 or more of the above.

[NICE's guideline on endometriosis, recommendation 1.3.1]

Equality and diversity considerations

Practitioners should be aware that some women may feel particularly anxious or have extreme difficulties undergoing some procedures such as abdominal and pelvic examinations. There could be a number of reasons for this, for example the woman's culture or age, or a learning disability. Consideration should therefore be given to carrying out an abdominal examination only, if this is clinically appropriate, and ensuring that the woman can bring a friend or relative as a chaperone if she wishes. Some women may also prefer to have a female practitioner carry out the examination.

Transgender men should have endometriosis considered as a possible diagnosis if they present with suspected endometriosis.