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CMScript: Focus on Endometriosis

Updated: Mar 27




March is Endometriosis Awareness Month, a period dedicated to raising awareness about this complex medical condition that affects millions of women worldwide, causing significant pain and impacting daily life.


What is Endometriosis?

Endometriosis is a complex medical condition where tissue, similar to the lining of the uterus (womb), grows outside the uterus. This tissue, known as endometrial tissue, can be found on the ovaries, fallopian tubes, outer surface of the uterus, and other organs within the pelvis. In rare cases, this tissue can spread beyond the pelvic organs.


During the menstrual cycle, endometrial tissue outside the uterus responds to hormonal changes by thickening, breaking down, and bleeding. Unlike the uterus lining that is shed during menstruation, this blood and tissue cannot leave the body as menstrual blood does, leading to inflammation, severe pain, and scarring. Endometriosis can cause a range of symptoms including pelvic pain, heavy periods, infertility, painful intercourse, and fatigue. It can significantly impact a person's quality of life, affecting their ability to work, study, and engage in daily activities.


Prevalence

Endometriosis affects many women and can start from the first menstrual period and last until menopause. Globally, it is estimated that the condition affects around 10% of women in the reproductive age group, that is, 15 to 44 years of age. However, there is no specific data on the extent of the disease in South Africa, highlighting the need for more research and awareness.


What is covered as PMB level of care?

Endometriosis is recognised as a Prescribed Minimum Benefit (PMB) condition. This means that the diagnosis, treatment, and care costs of endometriosis are covered under specific regulations, regardless of the member’s plan benefits. ICD10 codes N80.0, N80.1, and N80.2 are included in the PMBs under Diagnosis and Treatment Pair (DTP) code 434M.


The treatment component for DTP code 434M includes various options such as salpingectomy (surgical removal of one or both fallopian tubes), oophorectomy (surgical removal of one or both ovaries), hysterectomy (surgical removal of the uterus), as well as medical and surgical management. It is essential for healthcare practitioners to assist members in completing the necessary forms to register for PMB benefits, ensuring that the treatment is funded appropriately by the medical schemes.


By raising awareness and recognising endometriosis as a condition catered for under medical schemes, we can empower individuals affected to seek timely diagnosis and appropriate treatment.


info provided by CMS

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