What is the management of endometriosis?

Management of Endometriosis

The first-line treatment for endometriosis is hormonal therapy, with norethindrone acetate (starting at 5 mg daily and gradually increasing to 15 mg daily over 6-9 weeks) recommended as the primary medical intervention for symptom control. 1

Medical Management Options

First-Line Treatments

• Progestins

  • Norethindrone acetate: Start at 5 mg daily, increase by 2.5 mg every two weeks until reaching 15 mg daily; can be maintained for 6-9 months 1, 2
  • Depot medroxyprogesterone acetate: Effective for endometriosis-associated pain 1

• Combined Oral Contraceptives (COCs)

  • Provide consistent hormonal suppression
  • Contraindicated in patients with severe hypertension, complicated valvular heart disease, migraines with aura, or history of thromboembolism 1
  • In network meta-analyses, hormonal treatments including COCs led to clinically significant pain reduction compared to placebo 3

Second-Line Treatments

• GnRH Agonists with Add-Back Therapy

  • Minimum 3-month treatment course
  • Always use with add-back therapy to prevent bone mineral loss 1
  • Similar effectiveness to other hormonal options for pain relief

• Danazol

  • Equally effective to GnRH agonists for pain relief 1

Surgical Management

Indications for Surgery

• Persistent symptoms despite medical therapy
• Desire for improved fertility in appropriate candidates
• Definitive diagnosis when clinical suspicion remains high despite negative imaging

Surgical Options

1. Laparoscopic Excision/Ablation

   • Improves natural fertility by removing adhesions and restoring normal pelvic anatomy
   • Be aware of high recurrence rates (up to 44% within one year) 1

2. Hysterectomy with Removal of Endometriotic Lesions

   • Consider for patients who have completed childbearing and have severe symptoms unresponsive to other treatments
   • Note: Approximately 25% of patients experience recurrent pelvic pain after hysterectomy, and 10% require additional surgery 1, 3

Diagnostic Approach

Imaging

• Transvaginal Ultrasound (TVUS)

  • First-line imaging modality for detecting deep endometriosis 1
  • Expanded TVUS protocols have excellent performance for detection

• MRI Pelvis

  • Helpful for diagnosis of deep endometriosis and treatment planning
  • 92.4% sensitivity and 94.6% specificity for intestinal endometriosis 1

• Transrectal Ultrasound

  • Allows evaluation of bowel wall layers involved by endometriotic lesions
  • 97% sensitivity and 96% specificity for rectovaginal endometriosis 1

Fertility Management

• Endometriosis Fertility Index (EFI)

  • Validated clinical tool for predicting fertility outcomes after surgical staging 1

• Treatment Options

  • Intrauterine insemination (IUI): May benefit mild-moderate endometriosis but limited success in advanced disease
  • In vitro fertilization (IVF): Often most effective for advanced endometriosis 1
  • Women with stage 4 endometriosis have lower monthly fecundity rates (1-2% vs 15-20% in fertile couples) 1

Long-Term Management and Monitoring

• Regular assessment of symptom control every 3 months
• Monitor for side effects of hormonal therapy
• Be aware of recurrence rates (25-44% within 12 months of discontinuing hormonal treatment) 1
• Monitor for associated conditions: hypertension, hypercholesterolemia, and inflammatory conditions 1

Adjunctive Therapies

• Dietary modifications: Reducing dietary fat and increasing fiber can help lower circulating estrogen 1
• Vitamin D supplementation may reduce endometrial pain through increased antioxidant capacity 1

Important Caveats

1. Diagnostic Delay: Diagnosis is often delayed by 5-12 years after symptom onset, with most women consulting 3 or more clinicians prior to diagnosis 3

2. Treatment Limitations: 11-19% of individuals with endometriosis have no pain reduction with hormonal medications, and 25-34% experience recurrent pelvic pain within 12 months of discontinuing treatment 3

3. Multisystem Approach: Endometriosis should be viewed as a multisystem disease with potential impacts beyond reproductive health, requiring a personalized treatment approach 4

4. Long-term Hormonal Therapy: For many patients, long-term hormonal therapy may be necessary to control symptoms and prevent disease progression 5