When should I consider referring a patient with suspected endometriosis to a specialist for further evaluation?

Consider referring a patient with suspected endometriosis to a specialist endometriosis service (endometriosis centre) if they have suspected or confirmed:

• Endometrioma.
• Deep endometriosis involving the bowel, bladder, or ureter.
• Endometriosis outside the pelvic cavity.

Refer young women (aged 17 years or younger) with suspected or confirmed endometriosis to a paediatric and adolescent gynaecology service or specialist endometriosis service depending on local provision.

Also consider referral to a gynaecology service for further investigation and management if:

• Initial treatment is not effective, not tolerated, or contraindicated.
• Symptoms have a detrimental impact on activities of daily living.
• Persistent or recurrent symptoms of endometriosis.
• Pelvic signs of endometriosis are present but deep endometriosis is not suspected.

Referral should be considered even if pelvic or abdominal examination and ultrasound are normal, especially if symptoms persist.

Use transvaginal ultrasound to identify endometriomas and deep endometriosis to guide referral decisions.

Diagnostic laparoscopy may be considered for diagnosis if imaging is inconclusive and symptoms persist.