Clinical Practice Guideline

for

ENDOMETRIOSIS

Developed for the

Aerospace Medical Association

by their constituent organization

American Society of Aerospace Medicine Specialists

 

Overview: Endometriosis occurs when endometrial tissue proliferates outside the endometrial cavity.  It affects 5-10% of reproductive aged women and occurs most commonly between the ages of 25 and 29.  It is the underlying cause in significant percentage of patients presenting with pelvic pain.  Symptoms of endometriosis include pelvic pain, dysmenorrhea, dyspareunia, and/or infertility.  Pain can be located in the lower abdominal and/or lower back, and occur with exercise, micturition, or defecation.  The etiology of endometriosis is not well understood and is probably multifactorial.  The physical exam may reveal adnexal or uterine tenderness, a pelvic mass, or tender rectovaginal nodules.  However, many patients have a normal pelvic examination.  Consequently, the diagnosis is made primarily by direct visualization, usually via laparoscopy.  For the primary care provider the first line management includes the use of non-steroidal anti-inflammatory drugs (NSAIDs) and combination oral contraceptives pills (OCPs).  Other medications (danazol, gonadotropin releasing hormone agonists such as Lupron® or Zoladex®, provera, and depoprovera) are available and effective in treating the symptoms of endometriosis; however, only NSAIDS, OCPs and Depo-Provera are waiverable medications.  It is generally recommended to get laparoscopic confirmation of the diagnosis before beginning medication use.  Surgical therapy is the preferred treatment for patients with infertility and can be done by removing or destroying the endometriosis lesions.  More definitive surgery involves a hysterectomy and bilateral salpingo-oophorectomy.

 

Aeromedical Concerns: Pain associated with endometriosis usually begins as low grade discomfort and may progress over hours or days to severe discomfort that is distracting.  It is not expected to be acutely incapacitating.  Menorrhagia, often associated with endometriosis, can cause a gradual onset anemia.  Medical therapy should consist of medications that are aeromedically acceptable, such as NSAIDs and OCPs.  However, it should be pointed out, the first need is to treat your patient to the standard of care, secondary is to treat so that your patient’s condition/therapy is waiverable for aviation duties.  If various treatments are equally effective then pick the one most likely to be waiverable.

 

Medical Work-up: An aeromedical summary (waiver request) should contain, at a minimum, the following: a) history of symptoms, b), gynecological evaluation report, c) treatments used, d) any current medications or ongoing treatments and e) the latest hematocrit.

 

Aeromedical Disposition (military): The graph below describes the options for a female aviator with endometriosis:

 

Flying Class

Medication/Treatment Required

for Symptom Control of Endometriosis

Potentially Waiverable

 

 

Initial Flying Training

NSAIDs, OCPs, Depo-Provera

 

 

Danazol, gonadotropin releasing hormone agonists

 

Surgery

No

 

 

No

 

 

No

 

Pilots

NSAIDs, OCPs, Depo-Provera

 

 

Danazol, gonadotropin releasing hormone agonists

 

Surgery

Yes

 

 

No

 

 

Yes

 

Non-Pilot Aviators

NSAIDs, OCPs, Depo-Provera

 

 

Danazol, gonadotropin releasing hormone agonists

 

Surgery

Yes

 

 

No

 

 

Yes

 

 

 

 

Aeromedical Disposition (civilian):

 

Waiver Experience (military): Review of a military waiver database revealed 40 endometriosis cases.  Twenty-seven women with endometriosis, asymptomatic with or without medications were granted waivers.  Thirteen of the 40 cases were disqualified; five had symptoms not controlled or on nonwaiverable medications, four were initial non-pilot applicants and diagnosis was either recent and/or length of control of symptoms was short, and four had other disqualifying diagnoses. 

 

Waiver Experience (civilian): Endometriosis along with symptoms is disqualifying.  The airman should provide a detailed current status report along with appropriate testing.  In cases with demonstrated endometriosis that are controlled on various treatments are generally issued an authorization (waiver) with appropriate follow-up reporting.  All of the recognized treatments are acceptable as long as there no side effects that are adverse to the flying environment. 

 

 

References:

 

1. Carr, BR, Bradshaw.  Disorders of the ovary and female reproductive tract.  In:  Harrison’s Principles of Internal Medicine.  14th ed. McGraw-Hill Companies, Inc.; 1998.  p. 2115.

 

2. National Guideline Clearinghouse: Medical management of endometriosis.  Obtained on November 22, 2006 from:  http://www.guideline.gov/summary/summary.aspx?doc_id=3961

 

3. Prentice, A.  Endometriosis.  BMJ 2001; 323(7304):  93-5.

 

4. Wellbery, C.  Diagnosis and treatment of endometriosis.  Am Fam Physician 1999; 601753-68  Obtained on November 22, 2006 from:  http://www.aafp.org/afp/991015ap/1752.html

 

 

7/22/07