What are the treatment options for endometriosis?

Treatment Options for Endometriosis

First-line hormonal therapies, including combined oral contraceptives and progestins, are the recommended initial treatment for endometriosis, with surgical intervention reserved for cases where medical management fails. 1

First-Line Treatment Options

Hormonal Therapies

• Combined Oral Contraceptives (COCs)

  • Recommended as first-line treatment, preferably in continuous regimen
  • Standard starting dose: 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate
  • Provides consistent hormonal suppression and reduces frequency of withdrawal bleeding 1
  • Contraindicated in patients with severe uncontrolled hypertension, ongoing hepatic dysfunction, complicated valvular heart disease, migraines with aura, history of thromboembolism 1

• Progestins

  • Equally effective first-line option with high efficacy and reduced side effects 1
  • Options include:
    • Norethindrone acetate: Initial dose of 5 mg daily for two weeks, increasing by 2.5 mg every two weeks until reaching 15 mg daily; can be maintained for 6-9 months 2
    • Depot medroxyprogesterone acetate (DMPA)
    • Dienogest: Recently become one of the most used drugs for all endometriosis phenotypes 3
    • Progestin-loaded IUD: Valid alternative for long-term treatment 3

Symptomatic Management

• NSAIDs for pain management
• Dietary changes and exercise may help manage symptoms (limited evidence) 1

Second-Line Treatment Options

GnRH Agonists

• Effective for pain relief when used for at least three months
• Should always be used with add-back therapy to reduce bone mineral loss 1
• Induces iatrogenic menopause, reducing dysmenorrhea and pain symptoms 3
• Side effects include hot flashes and bone loss, which can be mitigated with add-back therapy 3

Danazol

• Equally effective to GnRH agonists for pain relief when used for at least six months
• Consider when first-line treatments fail 1
• Limited use due to availability of better-tolerated hormonal drugs 4

Aromatase Inhibitors

• Limited long-term efficacy and safety data
• Should be administered only in women with symptoms refractory to conventional therapies in a clinical research setting 4

Surgical Interventions

Laparoscopic Surgery

• Considered when hormonal therapies are ineffective or contraindicated
• Provides significant pain reduction during first six months
• Up to 44% of women experience symptom recurrence within one year 1
• Involves removal of endometriotic lesions and restoration of pelvic anatomy 5

Hysterectomy with Removal of Endometriotic Lesions

• Recommended for patients who have completed childbearing and have severe symptoms unresponsive to initial treatments 1
• Approximately 25% of patients experience recurrent pelvic pain after hysterectomy
• 10% require additional surgery 1

Treatment Considerations and Monitoring

Duration and Follow-up

• 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
• Follow-up recommended 1-3 months after initiating therapy to assess efficacy and side effects
• Annual clinical review recommended for patients on long-term therapy 1

Treatment Escalation

• Should not be delayed when first-line therapies fail
• Treatment pathway: First-line (COCs/progestins) → Second-line (GnRH agonists/danazol) → Surgical intervention → Hysterectomy (if childbearing complete) 1, 6

Common Pitfalls to Avoid

1. Delaying treatment escalation when first-line therapies fail
2. Using GnRH agonists without add-back therapy
3. Discontinuing hormonal therapy too early
4. Using progestins alone in women with endometriosis who have undergone oophorectomy 1
5. Assuming normal physical examination and imaging exclude the diagnosis 6
6. Relying solely on medical treatment for women actively seeking pregnancy, as reproductive prognosis is not improved by medical treatment 7

Efficacy Considerations

• Hormonal treatments lead to clinically significant pain reduction compared with placebo
• 11-19% of individuals have no pain reduction with hormonal medications 6
• Similar efficacy has been observed across various hormonal therapies 7
• Medical treatments are not curative and often need to be continued for years or until pregnancy is desired 7