Investigating the diagnosis and management of women with Endometriosis : A study of diagnostic tests, treatment strategies and quality of evidence on the management of endometriosis.
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The aim of this thesis is to investigate the diagnosis and management of endometriosis amongst women with pain or subfertility through a series of systematic reviews and primary studies. I will also evaluate the quality of information available to researchers, clinicians and patients on the management of endometriosis. Endometriosis is the presence of endometrial like cells outside the uterus, commonly within the pelvis. The disease is characterised by benign fibrosis and tissue invasion of endometrial like cells in surrounding structures such as the peritoneum, ovary, bowel, and bladder. The commonest symptoms reported by women with endometriosis are pain and subfertility. Non-invasive diagnostic tools have poor accuracy with the current gold standard diagnosis of laparoscopic surgery, biopsy and histological confirmation. I performed a diagnostic meta-analysis of the most researched diagnostic marker, Cancer Antigen125 (CA-125), establishing a cut-off value that had limited sensitivity but high specificity with potential as a rule-in test. I tested this in a multicentre cohort study of patients with pain and subfertility to assess the accuracy (CA-125) at the newly established cut off value. A systematic review assessing the reporting of outcomes and outcome measures identified 3 commonly reported outcomes: dysmenorrhoea, dyspareunia and pregnancy. There was heterogeneous outcome reporting across all Randomised control trials (RCT). A systematic review of international and national endometriosis guidelines revealed poor evidence synthesis from treatment effectiveness studies into guideline formation. A systematic and literature review of treatment effectiveness highlighted significant harms associated with ovarian surgery and oophorectomy. There is need for further research to develop accurate non-invasive diagnostic tests for endometriosis. The development of a collection of well-defined prioritised clinical outcomes will augment the usefulness of research to enhance the care for patients with endometriosis.
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