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The COVID-19 pandemic poses several important questions for healthcare providers on how best to deliver endometriosis care with these restrictions. Herein, we present clinical guidance on the management of endometriosis during the COVID-19 pandemic. This Commentary is endorsed by the World Endometriosis Society (WES) and the International Federation of Fertility Societies (IFFS)
Endometriosis clinical guidance during the COVID-19 pandemic
Mathew Leonardi1, Andrew Horne2, Mike Armour3, Stacey Missmer4, Horace Roman5, Luk
Rombauts6, Lone Hummelshoj7, Arnaud Wattiez8, George Condous1, and Neil Johnson9
1Nepean Hospital
2University of Edinburgh
3Western Sydney University
4Harvard University T H Chan School of Public Health
5Clinique Tivoli-Ducos
6Monash Medical School
8IRCAD, University Hospitals Strasbourg
9Neil Johnson Gynaecology Clinic
April 28, 2020
This opinion article is endorsed by the World Endometriosis Society (WES) and the Interna-
tional Federation of Fertility Societies (IFFS)
The COVID-19 pandemic has led to a dramatic shift in the clinical practice of women’s health and routine
care for endometriosis has been severely disrupted. Endometriosis is defined as an inflammatory disease
characterised by lesions of endometrial-like tissue outside the uterus that is associated with pelvic pain and/or
infertility.1It affects approximately 10% of reproductive age women worldwide, is diagnosed by surgically
visualisation or by radiological imaging, and is treated with hormone treatments or by laparoscopic removal
of lesions.2,3
Under the guidance of international gynaecological organisations4–6, many centres have temporarily ceased
offering outpatient appointments, diagnostic imaging for non-acute pelvic pain, surgery for endometriosis,
and fertility treatments. This means that endometriosis sufferers are be feeling particularly vulnerable and
that resultant stress and anxiety may contribute to a worsening of symptoms. The pandemic poses several
important questions for healthcare providers on how best to deliver care with these restrictions. Herein, we
present clinical guidance on the management of endometriosis during the COVID-19 pandemic (Fig. 1).
Are endometriosis patients a high-risk population?
To date, there is no evidence that women with endometriosis are at increased risk of COVID-19.7However,
women with endometriosis within the chest cavity (in the lungs or on the diaphragm), referred to as ‘tho-
racic endometriosis’, may be more at risk. Similarly, there is no evidence that COVID-19 will hasten the
progression/development of endometriosis. Nonetheless, the pandemic will likely contribute to a reduction
in quality of life secondary to a delay in diagnosis and/or the treatment of endometriosis owing to the tempo-
rary closure of outpatient services, (including complementary therapies), postponement of planned surgical
or fertility treatments, and an eventual increase in the waitlist for services once they resume. The extent of
the impact will depend on the duration of service postponement and regional resource variations (e.g. access
to operating theatre time when surgeries resume).
What management options are available during the COVID-19 pandemic?
We encourage individuals in need of help to seek a clinical assessment with their general practitioners (GP),
gynaecologists, physiotherapists, and/or complementary medical providers through telehealth avenues. Re-
ferral to a gynaecologist with expertise in endometriosis may also be appropriate to offset the new diagnostic
and therapeutic challenges faced during this time. Those with an established diagnosis who are seeking
help, regardless of their intentions to pursue surgical management, should discuss with their clinician the
potential to modify their current medication regimen. Some with suspected endometriosis may accept a
clinical diagnosis in the absence of imaging or laparoscopy and empirical medical therapy can be initiated.8
Caution in the use of non-steroidal anti-inflammatory drugs (NSAIDs), commonly used for endometriosis-
related pain, is being advised, because increase in angiotensin-converting enzyme 2 (ACE2) may predispose
to infection with COVID-19.9Those at low-risk of exposure may consider the benefits of NSAIDs outweigh
potential risk, deciding to continue use when needed. Conversely, those at higher-risk for acquisition (e.g.
continuing to attend work outside of their home or having household members whom are high-risk), may
benefit from using NSAIDs. Beyond traditional medical therapies, problem-focused interventions such as
education, modifying work/school/social life, taking advantage of virtual and telephone support provided
by national endometriosis organisations, improving sleep hygiene, low-intensity physical activity (including
pelvic exercises, yoga), dietary changes, application of heat, and medical cannabis should be considered, either
with the assistance of a healthcare provider via telehealth or independently by patients themselves. Similarly,
emotion-focused strategies, which include relaxation/mindfulness, acceptance of chronic illness (e.g. via
Acceptance and Commitment Therapy with the help of a clinical psychologist through telehealth), reducing
catastrophising, and improving a balance toward positive attitude can be considered. These strategies are
not unique to the COVID-19 pandemic and are recognised as an integral part of the usual multidisciplinary
treatment of endometriosis.
Patients should be aware that, if they experience acute exacerbations of their chronic pain, they may war-
rant urgent medical assessment, as such cases, especially those with suspected endometrioma or severe acute
recalcitrant exacerbation of pain, may require urgent surgery. However, most pain exacerbations are not life-
or organ-threatening and with appropriate counselling and support, a face-to-face consultation in the emer-
gency department may be avoided. Some GPs may find it challenging to confidently reassure patients that
they are safe to avoid an emergency department visit, so urgent telehealth consultation with a gynaecologist
or pain specialist may be helpful.
What will the endometriosis community learn from the COVID-19 experience?
This pandemic has been, and remains to be, a very difficult period for individuals with endometriosis.
However, this panel believes the consequences of the pandemic will yield a change in how clinical medicine for
endometriosis is conducted. Firstly, there may be an ongoing openness to telehealth. This could dramatically
minimise the geographic barriers to care that many women experience and facilitate the development of
endometriosis networks of expertise, which is recommended by the World Endometriosis Society.8Telehealth
may also be an appropriate alternative for patients with pain that limits their ability to travel to their
healthcare provider in some settings. Second, there may be increased awareness to self-management strategies
that have always existed, yet were under-utilised. Finally, the current situation mandates a more discerning
approach to surgery now and in the future, so that we ‘operate sparingly and operate well’. This approach
can be guided by preoperative triaging tools including advanced clinical algorithms and imaging strategies10
to avoid multiple repeated surgical procedures.
Figure 1: Clinical guidance summary for managing patients with endometriosis during the COVID-19 pan-
demic and beyond
Authors’ Roles
All authors meet justification criteria of authorship as per ICMJE:
1. substantial contributions to conception and design, or acquisition of data, or analysis and interpretation
of data,
2. drafting the article or revising it critically for important intellectual content,
3. final approval of the version to be published and
4. agreement to be accountable for all aspects of the work in ensuring that questions related to the
accuracy or integrity of any part of the work are appropriately investigated and resolved.
Funding Statement
Conflict of Interest
Dr. Leonardi reports grants from Australian Women and Children’s Research Foundation, outside the
submitted work. Prof. Horne reports grants from Chief Scientist Office, NIHR EME, MRC, Wellbeing of
Women, Ferring, and Roche Diagnostics during the conduct of the study; and honoraria for consultancy for
Ferring, Roche, and AbbVie, outside the submitted work. Dr. Armour reports grants from Metagenics and
Spectrum outside the submitted work. Prof. Missmer reports a grant and consulting fees from Abbvie, and
consulting fees from Roche outside the submitted work. Prof. Rombauts reports personal fees from Monash
IVF Group, grants from Ferring Australia, personal fees from Ferring Australia, non-financial support from
Merck Serono, non-financial support from MSD, non-financial support from Guerbet, outside the submitted
work; and Minority shareholder and Group Medical Director for Monash IVF Group and the President-Elect
of the World Endometriosis Society. Prof. Roman reports personal fees from Olympus, personal fees from
Ethicon, personal fees from Nordic Pharma, personal fees from Plasma Surgical Ltd, outside the submitted
work. Ms Hummelshoj reports personal fees from AbbVie, is the chief executive of the World Endometriosis
Society and the owner of, outside the submitted work. Prof. Condous reports personal
fees from Roche, personal fees from GE Healthcare, grants from Australian Women and Children’s Research
Foundation, outside the submitted work. Prof. Johnson reports personal fees from Guerbet, personal fees
from Vifor Pharma, grants and personal fees from Myovant Sciences, grants from AbbVie, personal fees from
Roche, outside the submitted work. Prof. Wattiez has nothing to disclose.
1. Johnson NP, Hummelshoj L, Adamson GD, Keckstein J, Taylor HS, Abrao MS, et al. World endometriosis
society consensus on the classification of endometriosis. Hum Reprod . 2017;32:315–24.
2. Zondervan KT, Becker CM, Missmer SA. Endometriosis. Longo DL, editor.N Engl J Med . 2020 Mar
3. Horne AW, Saunders PTK. SnapShot: Endometriosis. Cell . 2019 Dec;179:1677-1677.e1.
4. AAGL – Elevating Gynecologic Surgery. COVID-19: Joint Statement on Elective Surgeries [Internet].
2020 [cited 2020 Apr 5]. Available from:
5. American Society for Reproductive Medicine. COVID-19: Suggestions On Managing Patients Who Are
Undergoing Infertility Therapy Or Desiring Pregnancy [Internet]. 2020 [cited 2020 Mar 24]. Available from:
6. Bourne T, Leonardi M, Kyriacou C, Al-Memar M, Landolfo C, Cibula D, et al. ISUOG Consensus
Statement on rationalization of gynecological ultrasound services in context of SARS-CoV-2. Ultrasound
Obstet Gynecol . 2020;10.1002/uog.22047.
7. People Who Are at Higher Risk for Severe Illness |Coronavirus |COVID-19 |CDC [Internet]. [cited
2020 Apr 18]. Available from:
8. Johnson NP, Hummelshoj L, World Endometriosis Society Montpellier Consortium. Consensus on current
management of endometriosis. Hum Reprod . 2013 Jun 1;28:1552–68.
9. Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk
for COVID-19 infection? Lancet Respir Med . 2020 Apr;8:e21.
10. Leonardi M, Espada M, Choi S, Chou D, Chang T, Smith C, et al. Transvaginal Ultrasound Can
Accurately Predict the American Society of Reproductive Medicine Stage of Endometriosis Assigned at
Laparoscopy.J Minim Invasive Gynecol . 2020 Feb 22;10.1016/j.jmig.2020.02.014.
Full-text available
COVID-19 has led to new obstacles in the care for women with endometriosis. With many centers around the globe temporarily ceasing outpatient appointments, diagnostic imaging for non-acute pelvic pain, surgery for endometriosis, and fertility treatments, endometriosis sufferers may feel particularly vulnerable and that resultant stress and anxiety may contribute to a worsening of symptoms. Even as societies and healthcare systems begin to emerge from lockdown, COVID-19 will leave a permanent mark, whereby care for patients with endometriosis may never be the same again. This pandemic poses several important questions for healthcare providers on how best to deliver care with current restrictions and in post-COVID-19 healthcare settings. Herein, we present clinical advice on the management of endometriosis during and after the COVID-19 pandemic.
Study Objective To evaluate the diagnostic accuracy of transvaginal ultrasound in predicting a laparoscopic surgically assigned revised American Society of Reproductive Medicine (ASRM) endometriosis stage. Design Multicenter retrospective diagnostic accuracy study. Setting Patients attended one of two academic gynecologic ultrasound units and underwent laparoscopy by one of six surgeons in metropolitan Sydney, Australia between 2016 and 2018. Patients Two hundred and four patients with suspected endometriosis. Interventions Ultrasound followed by laparoscopy Measurements and Main Results Surgical cases were identified. The preoperative ultrasound report and surgical operative notes were each used to retrospectively assign an ASRM score and stage. The breakdown of surgical findings is as follows: ASRM 0 (i.e. no endometriosis), 24/204 (11.8%); ASRM 1, 110/204 (53.9%); ASRM 2, 22/204 (10.8%); ASRM 3, 16/204 (7.8%); ASRM 4, 32/204 (15.7%). The overall accuracy of ultrasound to predict the surgical ASRM stage is as follows: ASRM 1, 53.4%; ASRM 2, 93.8%; ASRM 3, 89.7%; ASRM 4, 93.1%; grouped ASRM 0/1/2, 94.6%; ASRM 3/4 of 94.6%. Ultrasound has better test performance in higher disease stages. When the ASRM stages are dichotomized, ultrasound has sensitivity and specificity for ASRM 0/1/2 of 94.9% and 93.8% and ASRM 3/4 of 93.8% and 94.9%. Conclusion Ultrasound has high accuracy in predicting mild, moderate, and severe ASRM stage of endometriosis and can accurately differentiate between stages when ASRM stages are dichotomized (nil/minimal/mild versus moderate/severe). This can have major positive implications on patient triaging to centers of excellence in minimally-invasive gynecology for advanced-stage endometriosis.
Endometriosis is chronic disorder with high socioeconomic impact defined by the presence of endometrial-like tissue ("lesions") outside the uterus. Genetic, hormonal, and immunological factors as well as endometrial progenitor cells are implicated in development of lesions. A hallmark of the disorder is chronic pain associated with neuroinflammation and changes in the CNS. Women with endometriosis are at increased risk of infertility. Current therapies are inadequate. To view this SnapShot, open or download the PDF.
Study question: What is the global consensus on the classification of endometriosis that considers the views of women with endometriosis? Summary answer: We have produced an international consensus statement on the classification of endometriosis through systematic appraisal of evidence and a consensus process that included representatives of national and international, medical and non-medical societies, patient organizations, and companies with an interest in endometriosis. What is known already: Classification systems of endometriosis, developed by several professional organizations, traditionally have been based on lesion appearance, pelvic adhesions, and anatomic location of disease. One system predicts fertility outcome and none predicts pelvic pain, response to medications, disease recurrence, risks for associated disorders, quality of life measures, and other endpoints important to women and health care providers for guiding appropriate therapeutic options and prognosis. Study design, size, duration: A consensus meeting, in conjunction with pre- and post-meeting processes, was undertaken. Participants/materials, setting, methods: A consensus meeting was held on 30 April 2014 in conjunction with the World Endometriosis Society's 12th World Congress on Endometriosis. Rigorous pre- and post-meeting processes, involving 55 representatives of 29 national and international, medical and non-medical organizations from a range of disciplines, led to this consensus statement. Main results and the role of chance: A total of 28 consensus statements were made. Of all, 10 statements had unanimous consensus, however none of the statements was made without expression of a caveat about the strength of the statement or the statement itself. Two statements did not achieve majority consensus. The statements covered women's priorities, aspects of classification, impact of low resources, as well as all the major classification systems for endometriosis. Until better classification systems are developed, we propose a classification toolbox (that includes the revised American Society for Reproductive Medicine and, where appropriate, the Enzian and Endometriosis Fertility Index staging systems), that may be used by all surgeons in each case of surgery undertaken for women with endometriosis. We also propose wider use of the World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonisation Project surgical and clinical data collection tools for research to improve classification of endometriosis in the future, of particular relevance when surgery is not undertaken. Limitations, reasons for caution: This consensus process differed from that of formal guideline development, although based on the same available evidence. A different group of international experts from those participating in this process may have yielded subtly different consensus statements. Wider implications of the findings: This is the first time that a large, global, consortium-representing 29 major stake-holding organizations, from 19 countries - has convened to systematically evaluate the best available evidence on the classification of endometriosis and reach consensus. In addition to 21 international medical organizations and companies, representatives from eight national endometriosis organizations were involved, including lay support groups, thus generating and including input from women who suffer from endometriosis in an endeavour to keep uppermost the goal of optimizing quality of life for women with endometriosis. Study funding/competing interests: The World Endometriosis Society convened and hosted the consensus meeting. Financial support for participants to attend the meeting was provided by the organizations that they represented. There was no other specific funding for this consensus process. Mauricio Abrao is an advisor to Bayer Pharma, and a consultant to AbbVie and AstraZeneca; G David Adamson is the Owner of Advanced Reproductive Care Inc and Ziva and a consultant to Bayer Pharma, Ferring, and AbbVie; Deborah Bush has received travel grants from Fisher & Paykel Healthcare and Bayer Pharmaceuticals; Linda Giudice is a consultant to AbbVie, Juniper Pharmaceutical, and NextGen Jane, holds research grant from the NIH, is site PI on a clinical trial sponsored by Bayer, and is a shareholder in Merck and Pfizer; Lone Hummelshoj is an unpaid consultant to AbbVie; Neil Johnson has received conference expenses from Bayer Pharma, Merck-Serono, and MSD, research funding from AbbVie, and is a consultant to Vifor Pharma and Guerbet; Jörg Keckstein has received a travel grant from AbbVie; Ludwig Kiesel is a consultant to Bayer Pharma, AbbVie, AstraZeneca, Gedeon Richter, and Shionogi, and holds a research grant from Bayer Pharma; Luk Rombauts is an advisor to MSD, Merck Serono, and Ferring, and a shareholder in Monash IVF. The following have declared that they have nothing to disclose: Kathy Sharpe Timms; Rulla Tamimi; Hugh Taylor. Trial registration number: N/A.
  • K T Zondervan
  • C M Becker
  • S A Missmer
Zondervan KT, Becker CM, Missmer SA. Endometriosis. Longo DL, editor.N Engl J Med. 2020 Mar 26;382:1244-56.
World Endometriosis Society Montpellier Consortium. Consensus on current management of endometriosis
  • N P Johnson
  • L Hummelshoj
Johnson NP, Hummelshoj L, World Endometriosis Society Montpellier Consortium. Consensus on current management of endometriosis. Hum Reprod. 2013 Jun 1;28:1552-68.