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gyn.dysmenorrhea.core.v1PRODUCTION
gyn.dysmenorrhea.core.v1

Dysmenorrhoea (primary vs secondary — endometriosis-aware)

obstetricschronicadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Primary (prostaglandin-mediated, no pathology) vs secondary (endometriosis commonest) dysmenorrhoea. Clinical ± imaging diagnosis is acceptable and EMPIRIC medical treatment may begin WITHOUT mandatory laparoscopy (ESHRE 2022 Becker PMID 35350465; ACOG CO 760 PMID 30461694)

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primary-vs-secondary frame set; empiric-treatment-without-laparoscopy paradigm acknowledged

Patient inputs (16)

Adolescent vs adult shifts the pre-test prior; early onset is the strongest risk factor for long diagnostic delay (ACOG CO 760; Brandes 2022 PMID 36514039)

Onset 6–12 mo post-menarche (ovulatory) favours primary; onset >2 yr post-menarche or at/near menarche raises secondary/endometriosis or obstructive anomaly (ACOG CO 760; ESHRE 2022)

Cyclical pain becoming non-cyclical/constant is a key endometriosis-suggestive pivot (ESHRE 2022 Becker)

Migraine-with-aura, VTE, smoking ≥35 yr, HTN, SLE, hepatic disease etc. gate combined-hormonal eligibility via US-MEC (calc.us_mec drives the hormonal step)

Pregnancy test in any reproductive-age woman with pelvic pain — anchors ectopic/early-pregnancy ddx before hormonal therapy (ACOG CO 760)

Failure of adequate empiric NSAID + hormonal trial at 3–6 mo RAISES the secondary/endometriosis posterior — a positive Bayesian update (ACOG CO 760 PMID 30461694)

eGFR / active PUD / GI-bleed / CV risk gate NSAID first-line dosing (Cochrane Marjoribanks 2015 PMID 26224322)

First-line imaging when secondary suspected / red flag / empiric-trial failure; endometrioma SpPin (Se 0.93/Sp 0.96), DIE Se 0.79/Sp 0.94 (Nisenblat Cochrane 2016 PMID 26919512)

MRI for DIE mapping / Müllerian anomaly when TVUS equivocal; DIE Se 0.94 (Nisenblat 2016); eMRI deep/ovarian Se ~92%/Sp ~87% (Avery 2024 PMID 38110143). Negative MRI does NOT exclude superficial endometriosis

Deep dyspareunia is a directional endometriosis/DIE pivot (ESHRE 2022; Bray-Beraldo 2018 PMID 29949818)

Cyclical dyschezia/dysuria/haematuria → deep infiltrating endometriosis (rectosigmoid/bladder); routes to TVUS/MRI mapping (Bray-Beraldo 2018 PMID 29949818; ESHRE 2022)

Subfertility with dysmenorrhoea raises the endometriosis posterior + changes the treatment goal (fertility-sparing) (ESHRE 2022; Horne BMJ 2022 PMID 36375827)

First-degree family history raises endometriosis prior (ESHRE 2022 Becker)

PID / post-PID adhesive disease is a secondary cause; routes to gyn.pelvic-inflammatory-disease.core.v1 sequelae context (CDC STI 2021)

LEEP/cone/ablation → cervical stenosis with cryptomenorrhoea/haematometra (RCOG; ESHRE 2022)

Copper IUD dysmenorrhoea (first 3–6 mo) or malposition is a reversible secondary cause; LNG-IUS conversely treats (ESHRE 2022; SOGC 437 2023 PMID 37244746)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationallife_threateningacute_severe_unilateral_pain_route_out
    Acute severe unilateral pelvic pain superimposed on dysmenorrhoea — exclude ovarian torsion / ruptured endometrioma / ectopic
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereobstructive_mullerian_anomaly_adolescent
    Adolescent (special pop: adolescent) with never-pain-free cyclical pelvic pain + pelvic mass ± primary amenorrhoea — obstructive Müllerian/outflow anomaly (imperforate hymen, obstructed hemivagina, non-communicating horn) (ACOG CO 760; ESHRE 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererefractory_endometriosis_gnrh_indication
    Refractory endometriosis-associated dysmenorrhoea (special pop: refractory-endometriosis-GnRH) after NSAID + first-line hormonal failure (ESHRE 2022; SPIRIT; Elaris)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_or_preconception_hormonal_hold
    Pregnancy confirmed, actively conceiving, or breastfeeding (special pop: pregnancy/lactation) — hormonal suppression is contraceptive and must be held; NSAIDs contraindicated (3rd-trimester ductal closure) and avoided peri-conception (ESHRE 2022; ACOG CO 760)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateempiric_trial_failure_secondary_workup
    No clinical improvement after an adequate 3–6-month empiric NSAID + hormonal trial — investigate secondary causes + adherence (ACOG CO 760)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateus_mec_restricted_hormonal_eligibility
    US-MEC category 3/4 comorbidity (special pop: US-MEC-restricted — migraine-with-aura, VTE history, smoking ≥35 yr, uncontrolled HTN, active hepatic disease) restricting combined-hormonal therapy (calc.us_mec)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesubfertility_fertility_sparing
    Dysmenorrhoea + subfertility (special pop: fertility-seeking) — hormonal suppression is contraceptive; coordinate fertility-sparing/ART (ESHRE 2022; Horne BMJ 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateiud_related_dysmenorrhea_reversible_secondary
    Copper-IUD new/worsened dysmenorrhoea in first 3–6 months OR malpositioned IUD on imaging (special pop: IUD-related) — a REVERSIBLE secondary cause; conversely LNG-IUS treats dysmenorrhoea (ESHRE 2022; SOGC 437 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderategnrh_prolonged_use_bmd_addback_deprescribe
    GnRH agonist/antagonist >6 months WITHOUT adequate add-back OR documented BMD decline (special pop: refractory-endometriosis-GnRH-add-back / deprescribing trigger) (ESHRE 2022; SPIRIT)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Dysmenorrhoea ladder: NSAID → hormonal (COC/LNG-IUS/progestin) → empiric-fail imaging → refractory-endometriosis GnRH ± add-back → fertility-sparing/chronic-pain (ESHRE 2022; ACOG CO 760; SOGC 437 2023)
axis: dysmenorrhea_stepwise_ladderstep 1 - Step 1 — NSAID first-line + non-pharmacologic adjuncts
Selected step "Step 1 — NSAID first-line + non-pharmacologic adjuncts" — Any dysmenorrhoea without NSAID contraindication; first-line for primary AND symptomatic baseline for secondary
  • naproxen
    first line
    NSAID
    500 mg PO then 250 mg q8h (or 500 mg BID) • PO • start with/just before flow ×3–5 d (max: 1000–1250 mg/day; lowest effective, shortest course)
    triggers: no_CKD_eGFR>=30, no_active_PUD, no_severe_CVD, not_pregnant
    Cochrane Marjoribanks 2015 PMID 26224322 — NSAID vs placebo pain relief OR 4.37 (95% CI 3.76–5.09); NSAID > paracetamol OR 1.89; in-repo validated rxcui 7646
    rxcui 7258
  • ibuprofen
    first line
    NSAID
    400–600 mg PO q6h with food • PO • q6h with flow ×3–5 d (max: 2400 mg/day; lowest effective, shortest course)
    triggers: nsaid_indicated, short_course_preferred
    Alternative first-line NSAID; no individual NSAID proven superior (Cochrane Marjoribanks 2015 PMID 26224322); in-repo validated rxcui 5640
    rxcui 5640
  • mefenamic acid
    first line
    NSAID_fenamate
    500 mg PO then 250 mg q6h • PO • q6h with flow ×2–3 d (max: 1500 mg/day ×≤7 d)
    triggers: nsaid_indicated, fenamate_preference
    Fenamate NSAID with antiprostaglandin + anti-PG-receptor action; classic dysmenorrhoea agent (Cochrane Marjoribanks 2015 PMID 26224322). rxcui OMITTED — no in-repo precedent (allowed at INTEGRATED)
    rxcui 6693
  • celecoxib
    contraindication substitute
    COX2_selective_NSAID
    400 mg PO then 200 mg q12h • PO • with flow ×3–5 d (max: 400 mg/day maintenance)
    triggers: GI_bleed_risk_or_PUD_history, no_high_CV_risk
    COX-2 selective when GI risk dominant + CV risk acceptable; no clear COX-2-vs-nonselective efficacy difference (Cochrane Marjoribanks 2015 PMID 26224322); in-repo validated rxcui 140587
    rxcui 140587
  • topical heat + regular aerobic exercise
    add on
    non_pharmacologic
    triggers: adjunct_to_nsaid, patient_preference
    Heat ≈ NSAID-equivalent analgesia; exercise vs no-treatment menstrual-pain SMD −1.86 (95% CI −2.06 to −1.66), 45–60 min ≥3×/wk (Cochrane Armour 2019 PMID 31538328)

outpatient playbook — drug actions (4)

  1. 1. NSAID first-line
    naproxen 500 then 250 mg q8h OR ibuprofen 400–600 mg q6h OR mefenamic acid 500 then 250 mg q6h • PO • start with/just before flow ×3–5 d
    trigger: Any dysmenorrhoea without NSAID contraindication
    Cochrane Marjoribanks 2015 PMID 26224322 — OR 4.37 vs placebo; NSAID > paracetamol OR 1.89
  2. 2. combined oral contraceptive (continuous preferred if endometriosis-suggestive)
    EE 20–30 µg + levonorgestrel 100–150 µg daily • PO • continuous (endometriosis-suggestive) or cyclic (primary)
    trigger: NSAID inadequate / contraception desired / endometriosis-suggestive; US-MEC category 1–2
    Cochrane Schroll 2023 PMID 37523477 — SMD −0.58 vs placebo; continuous vs cyclic SMD −0.73
  3. 3. LNG-IUS 52 mg OR oral progestin (dienogest 2 mg/d)
    LNG-IUS device OR dienogest 2 mg PO daily • intrauterine / PO • continuous
    trigger: Estrogen-contraindicated (US-MEC 3/4), endometriosis/adenomyosis-suggestive, or COC failed
    ESHRE 2022 PMID 35350465; dienogest VAS Δ −12.3 mm vs placebo (Strowitzki 2010 PMID 20444534)
  4. 4. GnRH antagonist (relugolix-CT) or agonist (leuprolide) + add-back
    relugolix 40 + estradiol 1 + norethisterone acetate 0.5 mg PO daily OR leuprolide depot 3.75 mg IM monthly + add-back • PO / IM • daily / monthly
    trigger: Refractory endometriosis after NSAID + first-line hormonal failure
    SPIRIT PMID 35717987 responder Δ ~45–48%; Elaris elagolix PMID 28525302; GnRH agonist requires add-back + BMD surveillance

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Recurrent crampy lower-abdominal/pelvic pain temporally locked to menses (ACOG CO 760; ESHRE 2022); Dysmenorrhoea + deep dyspareunia / dyschezia / cyclical dysuria / subfertility (endometriosis-suggestive cluster) (ESHRE 2022 Becker); Adolescent with menses-locked pain (primary if onset 6–12 mo post-menarche; endometriosis leading secondary cause) (ACOG CO 760).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Dysmenorrhoea (primary vs secondary — endometriosis-aware)** (gyn.dysmenorrhea.core.v1).
Phenotype framing: MECE: primary vs endometriosis vs adenomyosis vs leiomyoma/fibroid vs PID-sequela vs cervical-stenosis vs obstructive Müllerian/outflow anomaly vs ovarian (endometrioma/recurrent cyst) vs IUD-related; non-gyn mimics — IBS, interstitial cystitis/BPS, pelvic-floor myalgia, MSK (ESHRE 2022; SOGC 437 2023; Horne BMJ 2022)
Scope: Primary (prostaglandin-mediated, no pathology) vs secondary (endometriosis commonest) dysmenorrhoea. Clinical ± imaging diagnosis is acceptable and EMPIRIC medical treatment may begin WITHOUT mandatory laparoscopy (ESHRE 2022 Becker PMID 35350465; ACOG CO 760 PMID 30461694)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Dysmenorrhoea ladder: NSAID → hormonal (COC/LNG-IUS/progestin) → empiric-fail imaging → refractory-endometriosis GnRH ± add-back → fertility-sparing/chronic-pain (ESHRE 2022; ACOG CO 760; SOGC 437 2023)** — step "Step 1 — NSAID first-line + non-pharmacologic adjuncts".
1. naproxen 500 mg PO then 250 mg q8h (or 500 mg BID) PO start with/just before flow ×3–5 d (NSAID, first line) — Cochrane Marjoribanks 2015 PMID 26224322 — NSAID vs placebo pain relief OR 4.37 (95% CI 3.76–5.09); NSAID > paracetamol OR 1.89; in-repo validated rxcui 7646
2. ibuprofen 400–600 mg PO q6h with food PO q6h with flow ×3–5 d (NSAID, first line) — Alternative first-line NSAID; no individual NSAID proven superior (Cochrane Marjoribanks 2015 PMID 26224322); in-repo validated rxcui 5640
3. mefenamic acid 500 mg PO then 250 mg q6h PO q6h with flow ×2–3 d (NSAID_fenamate, first line) — Fenamate NSAID with antiprostaglandin + anti-PG-receptor action; classic dysmenorrhoea agent (Cochrane Marjoribanks 2015 PMID 26224322). rxcui OMITTED — no in-repo precedent (allowed at INTEGRATED)
4. celecoxib 400 mg PO then 200 mg q12h PO with flow ×3–5 d (COX2_selective_NSAID, contraindication substitute) — COX-2 selective when GI risk dominant + CV risk acceptable; no clear COX-2-vs-nonselective efficacy difference (Cochrane Marjoribanks 2015 PMID 26224322); in-repo validated rxcui 140587
5. topical heat + regular aerobic exercise (non_pharmacologic, add on) — Heat ≈ NSAID-equivalent analgesia; exercise vs no-treatment menstrual-pain SMD −1.86 (95% CI −2.06 to −1.66), 45–60 min ≥3×/wk (Cochrane Armour 2019 PMID 31538328)

Setting playbook (outpatient) — Distinguish primary vs secondary dysmenorrhoea, treat empirically WITHOUT mandatory laparoscopy, escalate the ladder by phenotype/US-MEC, and shorten endometriosis diagnostic delay (ESHRE 2022; ACOG CO 760)
6. NSAID first-line naproxen 500 then 250 mg q8h OR ibuprofen 400–600 mg q6h OR mefenamic acid 500 then 250 mg q6h PO start with/just before flow ×3–5 d — Any dysmenorrhoea without NSAID contraindication (Cochrane Marjoribanks 2015 PMID 26224322 — OR 4.37 vs placebo; NSAID > paracetamol OR 1.89)
7. combined oral contraceptive (continuous preferred if endometriosis-suggestive) EE 20–30 µg + levonorgestrel 100–150 µg daily PO continuous (endometriosis-suggestive) or cyclic (primary) — NSAID inadequate / contraception desired / endometriosis-suggestive; US-MEC category 1–2 (Cochrane Schroll 2023 PMID 37523477 — SMD −0.58 vs placebo; continuous vs cyclic SMD −0.73)
8. LNG-IUS 52 mg OR oral progestin (dienogest 2 mg/d) LNG-IUS device OR dienogest 2 mg PO daily intrauterine / PO continuous — Estrogen-contraindicated (US-MEC 3/4), endometriosis/adenomyosis-suggestive, or COC failed (ESHRE 2022 PMID 35350465; dienogest VAS Δ −12.3 mm vs placebo (Strowitzki 2010 PMID 20444534))
9. GnRH antagonist (relugolix-CT) or agonist (leuprolide) + add-back relugolix 40 + estradiol 1 + norethisterone acetate 0.5 mg PO daily OR leuprolide depot 3.75 mg IM monthly + add-back PO / IM daily / monthly — Refractory endometriosis after NSAID + first-line hormonal failure (SPIRIT PMID 35717987 responder Δ ~45–48%; Elaris elagolix PMID 28525302; GnRH agonist requires add-back + BMD surveillance)

Non-pharmacologic actions:
- Topical heat + regular aerobic exercise (Cochrane Armour 2019 PMID 31538328 — SMD −1.86)
- TVUS then MRI ONLY if secondary features / red flag / 3–6-mo empiric-trial failure (Nisenblat 2016 PMID 26919512)
- Gynaecology / endometriosis-centre referral for refractory / DIE / fertility / obstructive anomaly (ESHRE 2022)
- Chronic-pelvic-pain biopsychosocial multimodal pathway for central sensitisation (Horne BMJ 2022 PMID 36375827)
- Counsel: a normal scan does NOT exclude endometriosis; continue empiric treatment (Nisenblat 2016; Avery 2024 PMID 38110143)

AVOID / contraindication checks:
- NSAID block if eGFR<30 or active PUD or severe CVD or pregnancy (Cochrane Marjoribanks 2015 PMID 26224322)
- Combined hormonal block if US MEC category 3 or 4 (migraine with aura, VTE history, smoking ≥35 yr, uncontrolled HTN, active hepatic disease) — calc.us_mec
- GnRH agonist requires estrogen progestin add back from initiation and BMD surveillance (ESHRE 2022 PMID 35350465)
- GnRH antagonist monotherapy dose and duration limited by BMD and lipid (elagolix Elaris PMID 28525302) — prefer built in add back relugolix CT
- Depot medroxyprogesterone counsel reversible BMD loss and delayed fertility return (ESHRE 2022)
- Do NOT require laparoscopy before empiric medical therapy (ESHRE 2022 PMID 35350465 — paradigm shift)
- Conditional dependence 1:normal TVUS AND normal MRI do NOT lower the endometriosis posterior below the empiric treat threshold — the imaging LR− applies to endometrioma/DIE NOT to imaging occult SUPERFICIAL peritoneal disease; do not stop empiric treatment (Nisenblat Cochrane 2016 PMID 26919512; Avery 2024 PMID 38110143; Zhang 2020 PMID 32855690)
- Conditional dependence 2:empiric NSAID+adequate hormonal trial FAILURE at 3 6 months is itself a POSITIVE Bayesian update raising the secondary/endometriosis posterior (ACOG CO 760 PMID 30461694) — failure is a finding, not a non result
- Conditional dependence 3:endometriosis suggestive features are NON INDEPENDENT (deep dyspareunia, dyschezia, cyclical bowel/bladder, fixed retroverted uterus, POD obliteration co cluster via shared deep infiltrating disease mechanism) — do NOT naively multiply their LR+; the dynamic SLIDING SIGN LR+ 15.3 (Alcázar UOG 2022 PMID 35289968) substantially supersedes summed symptom LRs once positive
- Conditional dependence 4:deep dyspareunia/dyschezia LR+ is CONDITIONED on cyclical onset — the SAME symptom carries a higher endometriosis LR+ when it is menses locked/cyclical than when acyclic constant (acyclic constant shifts toward central sensitisation/non gyn mimic, not raising the endometriosis posterior) (ESHRE 2022 PMID 35350465; Bray Beraldo 2018 PMID 29949818)
- Conditional dependence 5:anovulation (PCOS) LOWERS the prior for prostaglandin mediated PRIMARY dysmenorrhoea (requires ovulation) — persistent menses locked pain in an anovulatory patient raises the SECONDARY prior (route endo.pcos.core.v1) (ACOG CO 760 PMID 30461694; ESHRE 2022 PMID 35350465)
- Conditional dependence 6:approaching menopause LOWERS the estrogen dependent endometriosis pain prior BUT does NOT exclude postmenopausal endometriosis — new/persistent post transition pain re raises the imaging threshold (ESHRE 2022 PMID 35350465 — postmenopausal disease explicitly addressed)
- Normal TVUS or MRI does NOT exclude superficial endometriosis do not stop empiric treatment (Nisenblat Cochrane 2016 PMID 26919512; Avery 2024 PMID 38110143)

Monitoring

Regimen monitoring:
- pain diary NRS or VAS each cycle (ACOG CO 760 PMID 30461694)
- empiric trial review at 3 to 6 months — failure triggers secondary-cause workup + is a positive endometriosis Bayesian update (ACOG CO 760 PMID 30461694)
- US-MEC re-screen at each hormonal change (calc.us mec)
- hormonal AE review — irregular bleeding RR 2.63, headache RR 1.51, nausea RR 1.64 (Cochrane Schroll 2023 PMID 37523477)
- GnRH step → DEXA/BMD + vasomotor + lipid surveillance; add-back adequacy (SPIRIT PMID 35717987; ESHRE 2022 PMID 35350465)
- NSAID renal/GI surveillance if prolonged or risk factors (Cochrane Marjoribanks 2015 PMID 26224322)

Setting (outpatient) monitoring:
- Pain diary each cycle; mandatory 3–6-month empiric-trial review point (ACOG CO 760 PMID 30461694)
- US-MEC re-screen at each hormonal change (calc.us_mec)
- Hormonal AE review — irregular bleeding/headache/nausea (Cochrane Schroll 2023 PMID 37523477)
- GnRH step → DEXA/BMD + vasomotor + lipid surveillance; add-back adequacy (SPIRIT PMID 35717987)

Follow-up plan: Long-term hormonal suppression to menopause or until a fertility window (endometriosis is chronic + potentially progressive — ACOG CO 760); preconception/fertility-sparing planning; chronic-pelvic-pain biopsychosocial multimodal pathway for central-sensitisation overlap (Horne BMJ 2022 PMID 36375827; Mardon BJOG 2022 PMID 34919325); return precautions (new acute severe pain, fever, pregnancy, neurologic/vascular hormonal AE)
- Close-out criterion: long-term suppression + fertility + chronic-pain plan + return precautions documented

Monitoring phase: Pain diary (NRS/VAS). MANDATORY 3–6-month empiric-trial review point: no clinical improvement → investigate secondary causes + adherence (the ACOG CO 760 T_test threshold; trial failure is itself a positive Bayesian update for endometriosis). Re-screen US-MEC at each hormonal change; GnRH step → add-back adequacy + BMD/DEXA surveillance + vasomotor/lipid review; hormonal-AE review (irregular bleeding RR 2.63, headache RR 1.51, nausea RR 1.64 — Cochrane Schroll 2023 PMID 37523477)

Disposition

Current setting: outpatient — Distinguish primary vs secondary dysmenorrhoea, treat empirically WITHOUT mandatory laparoscopy, escalate the ladder by phenotype/US-MEC, and shorten endometriosis diagnostic delay (ESHRE 2022; ACOG CO 760)

Disposition criteria:
- Continue outpatient ladder if controlled; specialist referral for refractory / DIE / fertility / anomaly / surgical candidacy (ESHRE 2022; ACOG CO 760)

Escalation triggers (move to higher acuity):
- Adolescent cyclical pain + pelvic mass ± primary amenorrhoea → urgent paediatric/adolescent gynae (obstructive Müllerian/outflow anomaly) (ACOG CO 760)
- Acute severe unilateral pain → exclude ovarian torsion / ruptured endometrioma (route to gyn.ovarian-torsion.v1)
- Fever + pelvic pain → PID pathway (gyn.pelvic-inflammatory-disease.core.v1; CDC STI 2021)
- 3–6-mo empiric-trial failure → imaging + gynae referral (ACOG CO 760 PMID 30461694)
- Subfertility + endometriosis-suggestive → reproductive-medicine referral, plan around fertility window (ESHRE 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Acute severe unilateral pelvic pain superimposed on dysmenorrhoea — exclude ovarian torsion / ruptured endometrioma / ectopic
- [SEVERE] Adolescent (special pop: adolescent) with never-pain-free cyclical pelvic pain + pelvic mass ± primary amenorrhoea — obstructive Müllerian/outflow anomaly (imperforate hymen, obstructed hemivagina, non-communicating horn) (ACOG CO 760; ESHRE 2022)
- [SEVERE] Refractory endometriosis-associated dysmenorrhoea (special pop: refractory-endometriosis-GnRH) after NSAID + first-line hormonal failure (ESHRE 2022; SPIRIT; Elaris)

Citations

- ESHRE Endometriosis Guideline 2022 (Becker, Hum Reprod Open) + ACOG Committee Opinion 760 (Dysmenorrhea & Endometriosis in the Adolescent) + ACOG endometriosis guidance + SOGC Adenomyosis Guideline 437 (2023) + NICE NG73 + RCOG + WES; reconciled 2026-05-17 [PMID:35350465](https://pubmed.ncbi.nlm.nih.gov/35350465/)
- Cited evidence (PMID 30461694) [PMID:30461694](https://pubmed.ncbi.nlm.nih.gov/30461694/)
- Cited evidence (PMID 37244746) [PMID:37244746](https://pubmed.ncbi.nlm.nih.gov/37244746/)
- Cited evidence (PMID 36375827) [PMID:36375827](https://pubmed.ncbi.nlm.nih.gov/36375827/)
- Cited evidence (PMID 36514039) [PMID:36514039](https://pubmed.ncbi.nlm.nih.gov/36514039/)

Last reconciled with current guidelines: 2026-05-17.
References
  • ESHRE Endometriosis Guideline 2022 (Becker, Hum Reprod Open) + ACOG Committee Opinion 760 (Dysmenorrhea & Endometriosis in the Adolescent) + ACOG endometriosis guidance + SOGC Adenomyosis Guideline 437 (2023) + NICE NG73 + RCOG + WES; reconciled 2026-05-17 — PMID:35350465
  • Cited evidence (PMID 30461694) — PMID:30461694
  • Cited evidence (PMID 37244746) — PMID:37244746
  • Cited evidence (PMID 36375827) — PMID:36375827
  • Cited evidence (PMID 36514039) — PMID:36514039