Evidence
This page contains a snapshot of featured content which highlights evidence addressing key clinical questions including areas of uncertainty. Please see the main topic reference list for details of all sources underpinning this topic.
BMJ Best Practice evidence tables
Evidence tables provide easily navigated layers of evidence in the context of specific clinical questions, using GRADE and a BMJ Best Practice Effectiveness rating. Follow the links at the bottom of the table, which go to the related evidence score in the main topic text, providing additional context for the clinical question. Find out more about our evidence tables.
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review) that focuses on the above important clinical question.
Confidence in the evidence is moderate or low to moderate where GRADE has been performed and there may be no difference in effectiveness between the intervention and comparison for key outcomes.
Population: Women with endometriosis
Intervention: GnRH agonists
Comparison: Other active treatments
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
GnRH agonist versus danazol | ||
Pelvic tenderness at 6 months (assessed with Total Symptom Severity Score [TSSS], scale not defined) | No statistically significant difference | Moderate |
Pelvic induration at 6 months (assessed with TSSS, scale not defined) | No statistically significant difference | Moderate |
Patients requiring surgery due to reappearance of symptoms and positive findings at pelvic examination at >12 months post treatment | No statistically significant difference | Moderate |
Quality of life (assessed with Psychological General Well-Being Index [PGWB] plus a modification of Part II of the Nottingham Health Profile) | No statistically significant difference | Low |
GnRH agonist versus levonorgestrel-releasing intrauterine system | ||
Quality of life at 6 months (assessed with PGWB scale 0–110) | No statistically significant difference | Moderate |
GnRH agonist versus depot medroxyprogesterone acetate (subcutaneous injections) | ||
Effect on daily activities (assessed by mean number of hours of productivity lost at employment at 18 months) | No statistically significant difference | High |
Effect on daily activities (assessed by mean number of hours of productivity lost at housework at 18 months) | No statistically significant difference | Moderate |
GnRH agonist plus placebo versus progestin plus placebo | ||
Paid working life (follow up: 6 months [at the end of treatment] and 12 months [6 months after the end of the treatment] assessed with Nottingham Health Profile) | No statistically significant difference | Very low |
Household work (follow up: 6 months [at the end of treatment] and 12 months [6 months after the end of the treatment] assessed with Nottingham Health Profile) | No statistically significant difference | Very low |
Vacation life (follow up: 6 months [at the end of treatment] and 12 months [6 months after the end of the treatment] assessed with Nottingham Health Profile) | No statistically significant difference | Very low |
Leisure (follow up: 6 months [at the end of treatment] and 12 months [6 months after the end of the treatment] assessed with Nottingham Health Profile) | No statistically significant difference | Very low |
Sexual life (follow up: 6 months [at the end of treatment] and 12 months [6 months after the end of the treatment] assessed with Nottingham Health Profile) | No statistically significant difference | Very low |
Disturbed sleep (follow up: 6 months [at the end of treatment] and 12 months [6 months after the end of the treatment] assessed with Goldberg's General Health Questionnaire) | No statistically significant difference | Very low |
Anxiety/depression (follow up: 6 months [at the end of treatment] and 12 months [6 months after the end of the treatment] assessed with Goldberg's General Health Questionnaire) | No statistically significant difference | Very low |
Motivation (follow up: 6 months [at the end of treatment] and 12 months [6 months after the end of the treatment] assessed with Coping Wheel, Inventory of Social Support and Interaction [ISSI] & demands, control & support questionnaire) | No statistically significant difference | Very low |
Emotional balance (follow up: 6 months [at the end of treatment] and 12 months [6 months after the end of the treatment] assessed with Coping Wheel, ISSI & demands, control & support questionnaire) | No statistically significant difference | Very low |
Structure (follow up: 6 months [at the end of treatment] and 12 months [6 months after the end of the treatment] assessed with Coping Wheel, ISSI & demands, control & support questionnarie) | No statistically significant difference | Very low |
Coping (follow up: 6 months [at the end of treatment] and 12 months [6 months after the end of the treatment] assessed with Coping Wheel, ISSI & demands, control & support questionnaire) | No statistically significant difference | Very low |
Psychological work demands (follow up: 6 months [at the end of treatment] and 12 months [6 months after the end of the treatment] assessed with Coping Wheel, ISSI & demands, control & support questionnaire) | No statistically significant difference | Very low |
Intellectual discretion at work (follow up: 6 months [at the end of treatment] and 12 months [6 months after the end of the treatment] assessed with Coping Wheel, ISSI & demands, control & support questionnaire) | No statistically significant difference | Very low |
Authority over decisions at work (follow up: 6 months [at the end of treatment] and 12 months [6 months after the end of the treatment] assessed with Coping Wheel, ISSI & demands, control & support questionnaire) | No statistically significant difference | Very low |
Social support at work (follow up: 6 months [at the end of treatment] and 12 months [6 months after the end of the treatment] assessed with Coping Wheel, ISSI & demands, control & support questionnaire) | No statistically significant difference | Very low |
GnRH agonist plus placebo versus danazol plus placebo | ||
Relief of painful symptoms: pelvic tenderness (follow up: 6 months measured with 4-point numerical scale) | No statistically significant difference | Very low |
Relief of painful symptoms: pelvic induration (follow up: 6 months measured with 4-point numerical scale) | No statistically significant difference | Very low |
Relief of painful symptoms: pelvic tenderness (follow up: 12 months) | No statistically significant difference | Very low |
Relief of painful symptoms: pelvic induration (follow up: 12 months) | No statistically significant difference | Very low |
GnRH agonist plus ethinylestradiol pill versus ethinylestradiol pill | ||
Pain at the end of treatment period (12 months): dysmenorrhoea (10-point Visual Analogue Scale [VAS]) | Favours intervention | Moderate |
Pain at the end of treatment period (12 months): non-menstrual pain (10-point VAS) | Favours comparison | Low |
GnRH agonist versus combined oral contraceptive pill | ||
Pain at the end of treatment period (6 months): dyspareunia (10-point VAS) | Favours intervention | Low |
Pain at the end of treatment period (6 months): non-menstrual pain (10-point VAS) | No statistically significant difference | Low |
Pain at 6 months after treatment period: dysmenorrhoea (10-point VAS) | No statistically significant difference | Very low |
Pain at 6 months after treatment period: dyspareunia (10-point VAS) | No statistically significant difference | Low |
Pain at 6 months after treatment period: non-menstrual pain (10-point VAS) | No statistically significant difference | Low |
Recommendations as stated in the source guideline Offer hormonal treatment (eg., combined oral contraceptive pill or a progestogen) to women with suspected, confirmed, or recurrent endometriosis.
Note The results in this table are based on pairwise analyses. The guideline committee noted that these results were broadly consistent with network meta-analysis results reported in the guideline, which support the use of hormonal therapy for pain relief in women with endometriosis, and which were used by the guideline committee for most decision-making. The guideline committee also stated that adverse events were varied across different types of hormonal treatment, but were consistent within drug classes; they noted that the benefit and harms of hormonal therapy should be discussed with women. The committee noted that the network meta-analysis found a higher risk of withdrawal due to adverse events and more serious adverse events (e.g., bone density changes) with GnRH agonists. They added that use of GnRH agonists requires guidance from a specialist. The guideline committee also noted that it should be explained to women with suspected or confirmed endometriosis that hormonal treatment can reduce pain and has no permanent negative effect on subsequent fertility. If hormonal treatment does not work, the guideline stated women should be referred to a gynaecology, specialist endometriosis, or paediatric and adolescent gynaecology service for investigation and treatment options.
This evidence table is related to the following section/s:
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review) that focuses on the above important clinical question.
Confidence in the evidence is very low or low where GRADE has been performed and the intervention may be more effective/beneficial than the comparison for key outcomes. However, this is uncertain and new evidence could change this in the future.
Population: Women with endometriosis
Intervention: Pharmacological therapy before or after surgery
Comparison: Placebo or no pharmacological therapy
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
Pain recurrence (visual analogue scale [VAS]): pelvic pain (follow up: 12 months) | Favours intervention | Moderate |
Pain recurrence (VAS): dysmenorrhoea (follow up: 12 months) | Favours intervention | Low |
Pain recurrence (VAS): deep dyspareunia (follow up: 12 months) | Favours intervention | Very low |
Pain recurrence (questionnaire based): abdominal pain at 12 months post-treatment completion | No statistically significant difference | Low |
Pain recurrence (questionnaire based): dysmenorrhoea at 12 months post-treatment completion | No statistically significant difference | Very low |
Pain recurrence (questionnaire based): dyspareunia at 12 months post-treatment completion | Favours intervention | Low |
Pain recurrence (Andersch and Milsom): pelvic pain (follow up: 12 months) | No statistically significant difference | Low |
Dysmenorrhoea (follow up: 12 months) | Favours intervention | Moderate |
Re-operation (women with endometriosis) | No statistically significant difference | Very low |
Endometriosis recurrence (dichotomous): disease recurrence at 5-6 months (follow up: 5-6 months) | No statistically significant difference | Very low |
Endometriosis recurrence (dichotomous) (follow up: 12 months) | No statistically significant difference | Very low |
Endometriosis recurrence (dichotomous) (follow up: 24 months) | No statistically significant difference | Very low |
Endometrioma recurrence (dichotomous): recurrence at 13-36 months | Favours intervention | Low |
Endometrioma recurrence (dichotomous) (follow up: 60 months) | No statistically significant difference | Low |
Patient satisfaction | No statistically significant difference | Low |
Recommendations as stated in the source guideline After laparoscopic excision or ablation of endometriosis, consider hormonal treatment (e.g., the combined oral contraceptive pill) to prolong the benefits of surgery and manage symptoms.
Note The results in this table are based on pairwise analyses. The included studies only cover pharmacological therapy after surgery versus surgery alone. There was no available evidence covering pharmacological therapy before surgery. The guideline committee prioritised pain relief, health-related QoL, and adverse events as critical outcomes. Many of the studies include gonadotrophin-releasing hormone (GnRH) agonists. They comment that the use of GnRH agonists requires guidance from a specialist due to risk of serious adverse effects. The guideline committee concluded that the combined oral contraceptive pill or long-acting reversible progestogen contraceptives were the preferable treatments, although not appropriate for women trying to conceive. The recommendation (above) was made based on the results of a separate network meta-analysis, which found that the addition of hormonal treatment after surgery (laparoscopic excision or ablation) reduced the risk of recurrence and symptoms.
This evidence table is related to the following section/s:
Cochrane Clinical Answers
Cochrane Clinical Answers (CCAs) provide a readable, digestible, clinically focused entry point to rigorous research from Cochrane systematic reviews. They are designed to be actionable and to inform decision making at the point of care and have been added to relevant sections of the main Best Practice text.
- What is the accuracy of transvaginal ultrasound (TVUS) for the diagnosis of endometriosis?
- What are the benefits and harms of treatments for pain and subfertility in women with endometriosis?
- What are the effects of progestagens and anti-progestagens in women with pain associated with endometriosis?
- How does long‐term gonadotrophin‐releasing hormone (GnRH) agonist therapy provided before in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) compare with standard IVF/ICSI alone for women with endometriosis?
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