What are the treatment options for endometriosis?

Treatment Options for Endometriosis

The most effective treatment approach for endometriosis includes NSAIDs as first-line therapy, followed by hormonal treatments such as oral contraceptives or progestins, with surgery reserved for cases resistant to medical management. 1, 2

First-Line Management: NSAIDs

• NSAIDs are recommended as the initial approach for immediate pain relief in patients with endometriosis pain 1, 2
• Should be used at appropriate doses and schedules for optimal pain control 3
• Effective for managing acute pain symptoms but often need to be combined with hormonal therapies for long-term management 4

Second-Line Management: Hormonal Therapies

Combined Oral Contraceptives (COCs)

• Provide effective pain relief compared to placebo and may be equivalent to more costly regimens 1, 2
• In network meta-analyses, COCs led to clinically significant pain reduction with mean differences between 13.15 and 17.6 points on a 0-100 visual analog scale 4
• Considered first-line hormonal treatment for women not seeking immediate pregnancy 4

Progestins

• Effective alternatives with similar efficacy to other hormonal treatments 1, 2
• Options include:
  • Oral progestins (including dienogest, which has high specificity for progesterone receptors) 5
  • Depot medroxyprogesterone acetate (injectable) 1, 5
  • Levonorgestrel-releasing intrauterine system (LNG-IUS) 5, 6
• Dydrogesterone can effectively treat endometriosis-associated pelvic pain without suppressing ovulation 5

GnRH Agonists and Antagonists

• GnRH agonists for at least three months provide significant pain relief 1, 2
• Appropriate for chronic pelvic pain, even without surgical confirmation of endometriosis 3, 1
• When using GnRH agonists long-term, add-back therapy should be implemented to reduce bone mineral loss without reducing pain relief efficacy 3, 1, 2
• Elagolix, an oral GnRH antagonist, is effective for managing moderate to severe endometriosis-associated pain 5

Third-Line Options

• Aromatase inhibitors are used as second-line drugs for managing endometriosis-associated pelvic pain 5, 6
• They prevent the conversion of steroid precursors to estrogens, both peripherally and at the ovarian level 5

Surgical Management

• Surgery provides significant pain reduction during the first six months following the procedure 1, 2
• For severe endometriosis, medical treatment alone may not be sufficient, and surgical intervention should be considered 2, 4
• Surgical options include:
  • Laparoscopic removal of endometriotic lesions 4
  • Hysterectomy with surgical removal of lesions when initial treatments are ineffective 4
• Important caveats:
  • Up to 44% of women experience symptom recurrence within one year after surgery 1, 2
  • Approximately 25% of patients who undergo hysterectomy for endometriosis experience recurrent pelvic pain 4
  • 10% undergo additional surgery, such as lysis of adhesions, to treat persistent pain 4

Complementary Approaches for Pain Management

• Heat application to the abdomen or back may help reduce cramping pain 3, 2
• Acupressure on specific points may help reduce pain 3, 2
• Aromatherapy with lavender may increase satisfaction and reduce pain or anxiety 3, 2

Important Considerations and Pitfalls

• Despite multiple treatment options, there is no medical therapy proven to completely eradicate endometriosis lesions 3, 2, 4
• 11-19% of individuals with endometriosis have no pain reduction with hormonal medications 4
• 25-34% experience recurrent pelvic pain within 12 months of discontinuing hormonal treatment 4
• 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 2
• Diagnosis is often delayed, averaging 5-12 years after symptom onset, with most women consulting 3 or more clinicians prior to diagnosis 4
• Hormone replacement therapy with estrogen is not contraindicated following hysterectomy and bilateral salpingo-oophorectomy for endometriosis 1