What are the treatment options for endometriosis?

Treatment Options for Endometriosis

First-line treatment for endometriosis should be hormonal therapies, specifically combined oral contraceptives (COCs) in a continuous regimen or progestins such as norethindrone acetate, depot medroxyprogesterone acetate, and dienogest, as they effectively reduce pain symptoms and improve quality of life in most patients. 1

First-Line Treatment Options

Hormonal Therapies

• Combined Oral Contraceptives (COCs)

  • Preferably used in a continuous regimen to provide consistent hormonal suppression
  • Standard starting dose: 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate
  • Particularly useful for severe dysmenorrhea
  • Contraindicated in patients with severe uncontrolled hypertension, ongoing hepatic dysfunction, complicated valvular heart disease, migraines with aura, history of thromboembolism 1

• Progestins

  • Norethindrone acetate: Initial dose 5 mg daily, can be increased by 2.5 mg every two weeks up to 15 mg daily for 6-9 months 2
  • Depot medroxyprogesterone acetate (DMPA)
  • Dienogest
  • Progestin-loaded IUD (levonorgestrel-releasing intrauterine system)
  • Effective for all endometriosis phenotypes for long-term treatment 1

Pain Management

• NSAIDs for pain relief, especially during menstruation 1, 3
• Lifestyle modifications: Dietary changes and exercise may help manage symptoms, though evidence is limited 1

Second-Line Treatment Options

When first-line therapies fail or are contraindicated:

• GnRH Agonists

  • Effective for pain relief when used for at least three months
  • Must be used with add-back therapy (including estrogens) to reduce bone mineral loss
  • Add-back therapy can be introduced before the third month to prevent side effects 1, 4

• GnRH Antagonists (e.g., elagolix)

  • Emerging therapy with promising results
  • Limited data available on long-term use 1, 5

• Danazol

  • Equally effective to GnRH agonists for pain relief when used for at least six months
  • Less favorable side effect profile compared to other options 1, 3

Third-Line Treatment Options

• Aromatase Inhibitors
  • Should be considered experimental therapies
  • Used only in patients with symptoms resistant to other therapies
  • Limited to short-term use (6 months) due to side effects
  • Requires add-back therapy 1, 6, 3

Surgical Interventions

• Laparoscopic removal of endometriotic lesions

  • Consider when hormonal therapies are ineffective or contraindicated
  • Provides significant pain reduction during the first six months
  • Up to 44% of women experience symptom recurrence within one year 1, 7

• Hysterectomy with removal of endometriotic lesions

  • Consider for patients who have completed childbearing and have severe symptoms resistant to other treatments
  • Approximately 25% of patients experience recurrent pelvic pain after hysterectomy
  • About 10% require additional surgery 1, 7

Treatment Duration and Follow-up

• Long-term therapy is often necessary as symptoms frequently recur after treatment cessation
• Approximately 25-34% of patients experience recurrent pelvic pain within 12 months of discontinuing hormonal treatment 1, 7
• Follow-up 1-3 months after initiating treatment to assess efficacy and side effects
• Annual clinical review recommended for patients on long-term therapy 1

Common Pitfalls to Avoid

• Delaying treatment escalation when first-line therapies fail
• Using GnRH agonists without add-back therapy
• Discontinuing hormonal therapy too early
• Using progestins alone in women with endometriosis who have undergone oophorectomy 1
• Preoperative hormonal treatment is not supported for the sole purpose of reducing complications or recurrence, or facilitating surgical procedures 4

Special Considerations

• For patients undergoing fertility-preserving therapy, medroxyprogesterone acetate (MPA) or megestrol acetate (MA) is recommended 1
• After surgical treatment, hormonal therapy (COCs or LNG-IUS) is recommended to prevent pain recurrence and improve quality of life 4
• For prevention of endometrioma recurrence, continuous COC is advised and should be maintained as long as tolerance is good 4