Diagnosis and management of endometriosis: summary of updated NICE guidance

Dear Editor

This NICE guidance on endometriosis is based on the 1922 narrative that deposits of ectopic endometrium cause pain and infertility though no mechanisms are desribed. A better, 2024 narrative is that injuries to interstitial and isthmic uterine nerves cause retrograde menstruation, pelvic pain and infertility (1). Such injuries result from 1) straining on the toilet, 2) difficult first labours, 3) surgical evacuation of the uterus.

Readers may confirm the close clinical association between straining on the toilet and chronic pelvic pain by simply asking teenagers with chronic pelvic pain about their bowel habits. It has a specific, neuro-immuno-histochemical signature with injured nerves surrounding narrowed arterioles that cause the characteristic premenstrual symptoms (2). Diagnosis is by clinical history with a supporting ultrasound scan to exclude ovarian cysts. Advice is specific to the preceding injury.

Clinical guidelines cement incorrect clinical narratives in place. Clinical care cannot improve whilst this 1922 narrative remains in place.

1) Quinn MJ. Mechanisms of pain and retrograde menstruation in endometriosis. Am J Obstet Gynecol. 2024 Oct;231(4):e151-e152.

2) Atwal G, du Plessis D, Armstrong G, Slade R, Quinn M. Uterine innervation after hysterectomy for chronic pelvic pain with, and without, endometriosis. Am J Obstet Gynecol. 2005 Nov;193(5):1650-5.