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
2University of Edinburgh
3Western Sydney University
4Harvard University T H Chan School of Public Health
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
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
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
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.
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 Endometriosis.org., 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.
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