What are the treatment options for endometriosis?

Treatment Options for Endometriosis

Medical management with hormonal therapy should be considered first-line treatment for endometriosis-associated pain in women not seeking immediate pregnancy, with surgical interventions reserved for those who fail medical therapy or have specific indications. 1, 2

First-Line Medical Treatments

Progestins

• Norethindrone acetate: FDA-approved for endometriosis
  • Initial dosage: 5 mg daily for two weeks
  • Increase by 2.5 mg every two weeks until reaching 15 mg daily
  • Continue for 6-9 months or until breakthrough bleeding requires temporary cessation 3
  • Recommended by ACOG as first-line treatment 1

Combined Hormonal Contraceptives (COCs)

• Provide consistent hormonal suppression
• Effective for pain relief
• Contraindications: severe hypertension, complicated valvular heart disease, migraines with aura, history of thromboembolism 1

Other Progestin Options

• Dienogest: Effective for all endometriosis phenotypes for long-term treatment 4
• Depot medroxyprogesterone acetate: Effective for endometriosis-associated pain 1
• Levonorgestrel-releasing intrauterine system: Particularly effective option 5

Second-Line Medical Treatments

GnRH Agonists with Add-Back Therapy

• Effective for pain relief by reducing estrogen production
• Minimum 3-month treatment course
• Must always be used with add-back therapy to prevent bone mineral loss 1
• Side effects include hot flushes and potential bone loss 4

GnRH Antagonists

• Newer option for endometriosis management 4

Third-Line Medical Treatments

• Aromatase inhibitors 2
• Danazol: Equally effective to GnRH agonists for pain relief 1

Surgical Interventions

Laparoscopic Excision/Ablation

• Consider for patients with persistent symptoms despite medical therapy
• Can improve natural fertility by removing adhesions and restoring normal pelvic anatomy
• Caution: Recurrence rates up to 44% within one year 1
• Equally effective as hormonal treatment in relieving pain at one-year follow-up 6

Hysterectomy with Removal of Endometriotic Lesions

• Consider for patients who have completed childbearing and have severe symptoms unresponsive to other treatments
• Important limitation: Approximately 25% of patients experience recurrent pelvic pain after hysterectomy, and 10% require additional surgery 1, 2

Treatment Selection Algorithm

1. For women not seeking immediate pregnancy with pain symptoms:

   • Start with progestins (norethindrone acetate) or COCs
   • If ineffective or not tolerated after 3 months, switch to alternative first-line option
   • If still ineffective, progress to second-line therapy (GnRH agonists with add-back)

2. For women seeking pregnancy:

   • Consider surgical removal of lesions to improve fertility
   • Evaluate using Endometriosis Fertility Index (EFI)
   • Consider assisted reproductive technologies based on disease severity

3. For women with specific complications:

   • Symptomatic bowel stenosis: Surgical intervention required
   • Ureteral stenosis with hydronephrosis: Surgical intervention required
   • Failed medical management: Consider surgery 6

Monitoring and Follow-Up

• Regular assessment of symptom control every 3 months
• Monitor for side effects of hormonal therapy
• Be aware that 11-19% of patients have no pain reduction with hormonal medications
• 25-34% experience recurrent pelvic pain within 12 months of discontinuing hormonal treatment 2

Important Considerations

• Diagnosis is often delayed (5-12 years after symptom onset)
• Transvaginal ultrasound is recommended as first-line imaging modality for detecting deep endometriosis
• MRI is helpful for diagnosis of deep endometriosis and treatment planning
• Endometriosis is associated with higher risk of hypertension, hypercholesterolemia, and inflammatory conditions 1

Adjunctive Therapies

• Dietary modifications: Reducing fat and increasing fiber may help lower circulating estrogen
• Anti-inflammatory plant-based diet components may be beneficial
• Vitamin D supplementation may reduce endometrial pain 1

Medical therapy should be prioritized before surgical interventions whenever possible, as hormonal treatments are effective in most patients and avoid the risks associated with surgery. However, surgical treatment remains essential for specific complications and when medical management fails.