What are the treatment options for endometriosis?

Treatment Options for Endometriosis

Hormonal therapies are the first-line treatment for endometriosis, with combined hormonal contraceptives and progestin-only options recommended for symptomatic premenopausal women who are not seeking immediate pregnancy. 1, 2

First-Line Treatment Options

Combined Hormonal Contraceptives (CHCs)

• Recommended for patients with no contraindications to estrogen 1
• Preferably used in a continuous regimen to provide consistent hormonal suppression 1
• Standard starting dose: 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate 1
• Contraindications include:
  • Severe uncontrolled hypertension
  • Ongoing hepatic dysfunction
  • Complicated valvular heart disease
  • Migraines with aura
  • History of thromboembolism or thrombophilia
  • Complications of diabetes 1

Progestin-Only Options

• Recommended for patients with contraindications to estrogen 1
• Options include:
  • Levonorgestrel-releasing IUD (LNG-IUD)
  • Norethindrone acetate
  • Depot medroxyprogesterone acetate (DMPA)
  • Dienogest 1
• Highly effective for all endometriosis phenotypes for long-term treatment 1

Treatment Efficacy and Considerations

• Network meta-analysis shows hormonal treatments lead to clinically significant pain reduction compared to placebo, with mean differences between 13.15 and 17.6 points on a 0-100 visual analog scale 2
• Approximately 11-19% of individuals experience no pain reduction with hormonal medications 2
• 25-34% experience recurrent pelvic pain within 12 months of discontinuing hormonal treatment 1, 2
• One-third of women demonstrate resistance to progestin therapy 1

Second-Line Treatment Options

• GnRH agonists and antagonists (with add-back therapy for prolonged treatment) 3, 2
• Should be used in selected cases (non-responders to first-line treatments) 3

Third-Line Treatment Options

• Aromatase inhibitors 2

Surgical Options

• Laparoscopic surgery for removal of endometriotic lesions when:

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

• Hysterectomy with removal of endometriotic lesions:

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

Treatment Algorithm

1. Start with first-line hormonal therapy:

   • For patients without contraindications to estrogen: Combined hormonal contraceptives
   • For patients with contraindications to estrogen: Progestin-only options

2. Evaluate treatment response after 3-6 months 1

3. If inadequate response to first-line therapy:

   • Switch to alternative first-line option OR
   • Escalate to second-line therapy (GnRH agonists/antagonists with add-back therapy)

4. If inadequate response to second-line therapy:

   • Consider third-line therapy (aromatase inhibitors) OR
   • Consider surgical options

5. For patients with completed childbearing and persistent severe symptoms:

   • Consider hysterectomy with removal of endometriotic lesions

Common Pitfalls to Avoid

• Delaying treatment escalation when first-line therapies fail 1
• Using GnRH agonists without add-back therapy 1
• Discontinuing hormonal therapy too early 1
• Using progestins alone in women with endometriosis who have undergone oophorectomy 1

Monitoring and Follow-Up

• Monitor for common side effects: amenorrhea, breakthrough bleeding, weight gain, and mood changes 1
• Measure blood pressure at follow-up visits for CHC users 1
• For unscheduled spotting or bleeding with implants or LNG-IUD, NSAIDs for 5-7 days may help 1
• Long-term therapy is often necessary as symptoms frequently recur after treatment cessation 1