Document type
Clinical pathways
Hertfordshire and West Essex ICB
Output type
Clinical Pathways
Endometriosis Pathway


Pathway Publish Date: October 2023
Next Review Date: January 2025

Exclude red flags and refer any patient with a suspicion of cancer on a 2ww referral pathway.

History and examination suggestive of endometriosis:


  • Chronic pelvic pain
  • Painful Periods (Dysmenorrhoea) with or without heavy menstrual bleeding
  • Deep dyspareunia
  • Dyschezia (pain on opening the bowels during and/or just preceding a menstrual period)
  • Proctalgia fugax (A severe shooting pain in the ano-rectum that is most noticed at the time of opening bowels)
  • Cyclical bladder or bowel symptoms
  • Subfertility associated with the above symptoms


  • Abdominal masses
  • Tender nodularity in the vaginal fornices¬∑
  • Visible vaginal endometriosis

Order a pelvic ultrasound to investigate for endometrioma

If endometrioma present, refer routinely to secondary care.

If an endometrioma is not present, treat symptomatically for 6 months with paracetamol/ NSAIDs and hormonal treatment if fertility is not immediately desired.

If symptoms of endometriosis persist despite conservative management, or if hormonal treatment is unsuitable, refer to gynaecology.

Many cases can be referred to general gynaecology for assessment and optimisation of treatment. Consider referring the following groups to Endometriosis Hertfordshire:

  • Where diagnosis has been made in secondary care and initial management strategy at the discretion of the general gynaecologist is felt to be not effective, not tolerated or is contraindicated.
  • Where diagnosis remains uncertain from clinical assessment or initial laparoscopy
  • Where it is felt to be more appropriate for an endometriosis specialist to perform the initial laparoscopy
  • Where a period of hormonal suppression has improved symptoms despite having had a negative laparoscopy, but the woman seeks alternative treatment options and a second opinion is deemed appropriate
  • Women wanting a hysterectomy as treatment of endometriosis
  • If the woman or GP specifically requests to be seen in this service
  • When considering surgical treatment of symptomatic endometrioma > 3cm in a woman aged > 35years who desires future fertility
  • Where there is evidence (radiologically or by clinical assessment) of deep infiltrating endometriosis
  • Where there may be involvement of other pelvic organs like bladder, bowel, and ureter
  • Where there is a suspicion of endometriosis outside of the pelvis e.g. thoracic endometriosis
  • Women with suspected endometriosis aged < 17 years
  • Women who require use of GnRH analogues for the treatment of endometriosis for more than 6 months without longer term definitive plan in place