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:
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