New Endometriosis Treatment Guidelines - What Does This Actually Mean for Patients?

Last week, the government announced that Health New Zealand will adapt the RANZCOG Australian Living Evidence Guideline: Endometriosis for use in New Zealand. As a patient with suspected or confirmed endometriosis, you might be wondering what this actually means for you.

Endometriosis is a chronic, debilitating condition in which endometrial-like tissue grows outside of the uterus. It affects approximately 1 in 7 women and people assigned female at birth. Patients with endometriosis often experience intense pain, along with many other symptoms, and there is an average of 10 years diagnostic delay. Māori and Pacifica patients can experience even longer delays. The current guideline produced in 2020 (which was not even a formal guideline), is now outdated and does not reflect current international best practice. For more background on endometriosis, you can read my article, What’s the Connection Between GLP-1 and Endometriosis?, where I explain more about the condition.

The guidelines explained here are the Australian Living Evidence Guidelines, which are to be adapted for New Zealand, so some details may change. The New Zealand guidelines are expected to be implemented mid-2027.

The RANZCOG guidelines highlights

Endometriosis is a chronic, multifactorial disease

These guidelines indicate that endometriosis is a chronic, multifactorial disease, which means patients often require input and care from other specialities, not just gynaecology. This may include support from chronic pain services, physiotherapy, mental health services, and colorectal and urology specialities. This is a huge step for patients with endometriosis. Unfortunately in many cases, endometriosis has not been treated like a chronic disease, with patients having fragmented care and needing to do significant amounts of research on their own to find different treatment and management options.

Diagnosis via imaging

Up until now, laparoscopic surgery has been the gold-standard for diagnosis of endometriosis. Now, diagnosis via transvaginal or abdominal ultrasound or MRI by an experienced specialist is recommended. However, it is important to note that if the imaging is normal, this does not necessarily mean that endometriosis is ruled out. Suspected endometriosis can still be treated by the following guidelines, with diagnosis via surgery after initial first-line treatment.

Hormonal treatment for endometriosis

For first-line hormonal treatment of endometriosis, any of the following therapies may be prescribed: oral combined contraceptive or progesterones including oral, injection, implant or IUD. These may be used in combination with pain relief as prescribed. First-line treatments are to be reviewed in 3 months. Second-line hormonal therapies are GnRH agonists and GnRH antagonists with add-back therapy.

Adolescent patients with suspected or confirmed endometriosis

The treatment pathway described in the guidelines can also apply to adolescent patients with suspected or confirmed endometriosis. However, patients should be referred to a gynaecologist with experience treating endometriosis in young people. Consideration also needs to be given to the appropriateness of transvaginal ultrasounds; abdominal ultrasound or MRI may be used instead.

Treatment pathway following the RANZCOG guidelines

Initial presentation

When you visit the GP, you will discuss your symptoms, personal and family health history, and support needs.

The most common symptoms of endometriosis as listed in the guidelines are:

• Severe painful periods
• Pain with sex (during or after)
• Infertility
• Pelvic pain
• Heavy menstrual bleeding

Less common symptoms include:

• Bowel symptoms including constipation, diarrhoea, or pain with bowel movements
• Severe tiredness
• Back pain
• Difficulty sleeping
• Headache
• Urinary symptoms
• Allergies

It is recommended that doctors take a history of any autoimmune disease or first-degree relatives with endometriosis or symptoms of endometriosis, as that may increase the chances of disease. The doctor may also do a pelvic exam to look for signs of endometriosis such as reduced pelvic organ mobility, pelvic organ enlargement or tenderness.

Your doctor may also discuss any co-existing conditions you may have, your treatment priorities (e.g. pain management), whether you are considering fertility in the near future, cultural background, the impact on your daily living, and any physical, psychosexual or emotional needs. This will guide the type of treatment and management your doctor may recommend.

The guidelines recommend that people with suspected or confirmed endometriosis may benefit from coordinated team-based care. Based on the discussions with your GP, they may refer you to any of the following services.

• Nurses (including community nurses and school nurses)
• Physiotherapists and other allied health practitioners
• Psychological support services
• Gynaecological services
  • Gynaecologists with expertise in endometriosis, including training in laparoscopic surgery
  • Gynaecology specialist nurses with expertise in endometriosis
• Fertility services
• Paediatric and adolescent gynaecologists
• Multidisciplinary pain management services with expertise in pelvic pain
• Gynaecological imaging
• Specialist surgical services including colorectal surgeons or urologists with an interest in endometriosis
• Sexual and reproductive health services
• Cultural health practitioners

At this stage, you may be prescribed a first-line hormonal treatment such as the combined oral contraceptive pill and progesterones including oral, injection, implant, and IUD options. Under the Australian guidelines, these can be used to treat suspected or confirmed endometriosis.

You may be referred to a gynaecologist if initial treatment is not effective or appropriate – if you are hoping to conceive, then hormonal treatment would not be appropriate for you, for example.

Diagnosis of endometriosis

If your symptoms are suggestive of endometriosis, you will be offered a transvaginal ultrasound, as this is the first-line method of diagnosis under the guidelines. A pelvic MRI may be an option if the ultrasound is not appropriate or unavailable, or if deep endometriosis is suspected. A transabdominal ultrasound may also be used.

If the ultrasound or MRI does not show evidence of endometriosis, this does not rule out superficial peritoneal disease and should still be treated following the guidelines.

The goal of a transvaginal ultrasound is to identify endometrioma (also called a chocolate cyst), identify any endometriosis lesions in the pelvis, and identify any other conditions that could be causing the symptoms. Any endometriosis identified on scans can be very useful for surgery planning, if that route is taken, particularly if endometriosis is found outside of the pelvis or other organs are involved.

Surgery may be considered after a trial period of the first-line hormonal therapies for patients with suspected or confirmed endometriosis, even if the imaging was normal.

Pharmacological treatment of suspected or confirmed endometriosis

Under the Australian guidelines, the first-line treatment of suspected or confirmed endometriosis is hormonal contraceptives. Whichever option you and your doctor decide on will be trialled for 3 months. If there is no improvement in pain or tolerability of the medication, an alternative first-line treatment may be tried. If you have confirmed endometriosis, you may be able to try a second-line hormonal treatment option such as a GnRH agonist or GnRH antagonist. If these treatments are used, add-back oestrogen therapy is recommended to prevent bone loss and menopausal symptoms.

If you are trying to conceive, then hormonal treatments will not be right for you. Your doctor may be able to refer you to a fertility specialist.

Alongside hormonal treatments (or instead of, if you prefer not to use hormonal treatments) you may be prescribed analgesics for pain management. Simple analgesics such as paracetamol can be prescribed alone or in combination with other analgesics. It is best to discuss with your doctor which pain medications are right for you.

Some things to note from the guidelines are that if opioids, such as codeine, are prescribed, they should be used at a minimum effective dose and for a limited time. Neuromodulators (medications that alter nerve activity and neurotransmitter levels) may also be used, but although there is a little evidence for their use in chronic pain, there is very limited evidence for their use in endometriosis.

There are four stages of endometriosis based on the location, depth, and amount of endometriosis lesions. However, treatment of confirmed endometriosis is to be aligned with your symptoms, treatment preferences and priorities rather than the stage of endometriosis, as we know that the severity of the disease stage does not directly correlate with the severity of symptoms.

Surgery for suspected or confirmed endometriosis

Laparoscopic surgery should be considered if endometriosis is suspected but not diagnosed from scans or if you have not responded to treatment.
Before you have a surgery for the treatment of endometriosis, your doctor will need to discuss a few things with you, such as:

• What it involves,
• That it may include treatment of lesions if they are found,
• That it may or may not improve your symptoms, regardless of whether endometriosis ends up being diagnosed or not,
• The possible benefits and harms of surgery, and
• The possibility of future surgery if there is bowel, bladder, or ureter involvement, or for recurrent endometriosis.

If you have endometrioma, excision surgery should always be performed, rather than ablation or sclerotherapy. This is because complete excision has been shown to have a lower rate of recurrence.

If you are not trying to conceive, you should be offered first or second line hormonal treatments after surgery. Hormonal suppression caused by these medications reduce the risk of disease recurrence and are recommended post surgery.

Sometimes patients have repeat surgeries for recurrent endometriosis. This is something to be considered by you and your specialist as there are risks associated with repeat surgeries.

Hysterectomy is often thought to ‘cure’ endometriosis, however, there is limited evidence of the effectiveness of hysterectomy to improve outcomes such as pain and does not necessarily cure endometriosis. Disease can recur even after a hysterectomy.

Non-pharmalogical treatment for endometriosis

As outlined above, you may be referred to or recommended to try non-pharmalogical treatments to help manage your symptoms. Many patients find these services beneficial.

• Pelvic physiotherapy may help with pelvic pain and pain with sex.
• Mental health services such as counselling may help improve quality of life and manage the psychological side of dealing with chronic endometriosis symptoms.
• Diet and supplement support may help improve pain and inflammation, but this should be personalised to you.
• Acupuncture may have short-term improvements in endometriosis-associated pain and quality of life.

Fertility

If you are trying to conceive and have suspected or confirmed endometriosis, laparoscopic surgery to remove superficial peritoneal endometriosis may improve chances of a viable pregnancy. If you have deep infiltrating endometriosis the costs and benefits of the surgery should be discussed with your specialist as there is no evidence for the improvement of fertility outcomes with surgery.

Post-menopausal women

This guideline does not cover the management of endometriosis in post-menopausal women.

Overall, the implementation of the RANZCOG Australian Living Evidence Guideline: Endometriosis is a huge step for patients with endometriosis. It will be interesting to see how Health New Zealand adapts the guideline for the New Zealand context, and what changes may emerge as a result.

References

Royal Australian and New Zealand College of Obstetricians and Gynaecologists. RANZCOG Australian Living Evidence Guideline: Endometriosis. 2025.

Ellis K, Munro D, Clarke J. Endometriosis Is Undervalued: A Call to Action. Front Glob Womens Health. 2022;3:902371. Published 2022 May 10. doi:10.3389/fgwh.2022.902371

Endometriosis New Zealand. 2026 Election Manifesto. 2026.