What is the treatment for endometriosis?

Treatment for Endometriosis

Hormonal therapies, particularly combined oral contraceptives (COCs) and progestins, are the first-line treatment options for endometriosis, with surgical intervention reserved for cases where hormonal treatments fail or are contraindicated. 1

First-Line Treatment Options

Hormonal Therapies

1. Combined Oral Contraceptives (COCs)

   • Recommended as first-line treatment, preferably in a continuous regimen
   • Standard starting dose: 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate
   • Provides consistent hormonal suppression and reduces withdrawal bleeding frequency 1
   • Contraindications: severe uncontrolled hypertension, hepatic dysfunction, complicated valvular heart disease, migraines with aura, thromboembolism history 1
   • Common side effects: irregular bleeding, headache, nausea (typically transient) 1

2. Progestins

   • Equally effective first-line options for pain management 1, 2
   • Options include:
     • Norethindrone acetate
     • Depot medroxyprogesterone acetate (DMPA)
     • Dienogest
   • Effective for all endometriosis phenotypes for long-term treatment 1, 3
   • Progestin-loaded IUDs are also an option 1

3. NSAIDs

   • Used for pain management 1

Second-Line Treatment Options

1. GnRH Agonists

   • Effective for pain relief when used for at least three months
   • Must be used with add-back therapy to reduce bone mineral loss 1
   • Side effects include hot flushes, insomnia, and vaginal dryness 4

2. Danazol

   • Equally effective to GnRH agonists for pain relief when used for at least six months 1

Surgical Intervention

1. Laparoscopic Surgery

   • Consider when hormonal therapies are ineffective or contraindicated 2
   • Significant pain reduction during first six months post-surgery
   • Up to 44% of women experience symptom recurrence within one year 1

2. Hysterectomy with Removal of Endometriotic Lesions

   • For patients who have completed childbearing and have severe symptoms
   • Consider when initial treatments are ineffective
   • Approximately 25% of patients experience recurrent pelvic pain after hysterectomy
   • 10% require additional surgery 1, 2

Treatment Considerations

Efficacy of Hormonal Treatments

• Network meta-analysis shows hormonal treatments (COCs, progestins, GnRH agonists) lead to clinically significant pain reduction compared with placebo 2
• Mean differences range between 13.15 and 17.6 points on a 0-100 visual analog scale 2
• Little difference in effectiveness among hormonal options 2

Treatment Duration and Recurrence

• Long-term therapy is often necessary as symptoms frequently recur after treatment cessation
• 25-34% of patients experience recurrent pelvic pain within 12 months of discontinuing hormonal treatment 1, 2
• 11-19% of individuals have no pain reduction with hormonal medications 2

Treatment Algorithm

1. Initial Assessment

   • Evaluate pain characteristics (dysmenorrhea, non-menstrual pelvic pain, dyspareunia)
   • Assess fertility desires 1

2. First-Line Treatment

   • For patients not desiring immediate pregnancy: COCs or progestins 2
   • For patients undergoing fertility-preserving therapy: medroxyprogesterone acetate or megestrol acetate 1

3. If First-Line Treatment Fails

   • Escalate to second-line therapy (GnRH agonists with add-back therapy or danazol) 1
   • Consider laparoscopic surgery to remove endometriotic lesions 1, 2

4. If Second-Line Treatment Fails

   • Consider third-line treatments (aromatase inhibitors) 2
   • For patients who have completed childbearing: consider hysterectomy with removal of endometriotic lesions 1, 2

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
• Overlooking the high recurrence rate after surgical intervention 1, 2

Monitoring and Follow-up

• Schedule follow-up 1-3 months after initiating COCs to assess efficacy and side effects
• Annual clinical review for patients on long-term therapy 1
• Monitor for common side effects of hormonal therapies