What are the treatment options for endometriosis?

Treatment Options for Endometriosis

Medical and surgical treatments for endometriosis should be selected based on symptom severity, desire for fertility, and patient preference, with hormonal therapies as first-line treatment for most patients who are not actively seeking pregnancy. 1, 2

First-Line Treatments

• NSAIDs are effective first-line agents for pain management in endometriosis 1
• Combined oral contraceptives provide effective pain relief compared to placebo and are equivalent to more costly regimens 3, 2
• Progestins (oral or depot medroxyprogesterone acetate) are effective alternatives with similar efficacy to other hormonal treatments 3, 1
  • Norethindrone acetate is FDA-approved for endometriosis treatment at an initial daily dosage of 5 mg for two weeks, with dosage increased by 2.5 mg every two weeks until reaching 15 mg per day 4
• Hormonal treatments (combined oral contraceptives, progestins) lead to clinically significant pain reduction compared with placebo in most patients 2

Second-Line Treatments

• GnRH agonists for at least three months provide significant pain relief 3, 1
  • When using GnRH agonists, add-back therapy should be implemented to reduce or eliminate bone mineral loss without reducing pain efficacy 3, 1
• GnRH antagonists (such as elagolix) are emerging as effective options for endometriosis pain management 5

Third-Line Treatments

• Aromatase inhibitors should be administered only in women with symptoms refractory to other conventional therapies in a clinical research setting 5
• Danazol is effective for pain relief when used for at least six months but has limited use due to the availability of better-tolerated hormonal drugs 3, 5

Surgical Management

• Surgery provides significant pain reduction during the first six months following the procedure 3, 2
• For severe endometriosis, medical treatment alone may not be sufficient 3
• Laparoscopic removal of lesions should be considered if first-line hormonal therapies are ineffective or contraindicated 2
• Up to 44% of women experience symptom recurrence within one year after surgery 3, 1
• Hysterectomy with surgical removal of lesions may be considered when initial treatments are ineffective 2
  • Approximately 25% of patients who undergo hysterectomy for endometriosis experience recurrent pelvic pain 2
  • Hormone replacement therapy with estrogen is not contraindicated following hysterectomy and bilateral salpingo-oophorectomy for endometriosis 3

Treatment Limitations and Considerations

• 11-19% of individuals with endometriosis have no pain reduction with hormonal medications 2
• 25-34% experience recurrent pelvic pain within 12 months of discontinuing hormonal treatment 2
• The pain associated with endometriosis has little relationship to the type of lesions seen by laparoscopy, but depth of lesions correlates with severity of pain 3
• Diagnosis is often delayed, averaging 5-12 years after symptom onset 2

Treatment Algorithm

1. Initial approach: NSAIDs for pain management combined with hormonal therapy (combined oral contraceptives or progestins) 1, 2
2. If first-line therapy fails: Try alternative hormonal therapy or progress to GnRH agonists with add-back therapy 3, 1
3. If second-line therapy fails: Consider surgical removal of endometriotic lesions 2
4. For severe, refractory cases: Consider hysterectomy with removal of all visible endometriotic lesions 2
5. For patients desiring pregnancy: Surgical treatment may be preferred as first-line approach 2

Endometriosis treatment should be continued long-term as it is a chronic, recurrent condition that requires ongoing management 2, 6.