From the Guidelines
Treatment for endometriosis should be individualized and may involve a combination of pain management, hormonal therapy, and sometimes surgery, with the goal of improving quality of life and reducing morbidity and mortality. According to the most recent evidence 1, the treatment approach should be based on the patient's individualized goals, and medical therapies can help temporize symptoms, while surgical excision by a specialist is considered the definitive treatment.
Medical Therapy
For pain relief, nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-800mg every 6-8 hours) or naproxen (500mg twice daily) can help manage symptoms. Hormonal treatments are often the first-line therapy, including:
- Combined hormonal contraceptives (birth control pills, patches, or rings), which can be taken continuously to prevent menstruation
- Progestin-only options like the levonorgestrel IUD (Mirena), medroxyprogesterone acetate injections (Depo-Provera, 150mg every 3 months), or norethindrone acetate (5-15mg daily) can effectively suppress endometrial growth
- GnRH agonists like leuprolide (3.75mg monthly injection) may be used for more severe cases, but are typically limited to 6-12 months due to bone density concerns and should be combined with add-back hormone therapy 1
Surgical Therapy
For patients not responding to medication or those with severe symptoms, laparoscopic surgery to remove endometrial implants can provide relief. The use of imaging before surgery, such as expanded protocol transvaginal ultrasound (TVUS) or MRI, can help inform patient decision making, is important for surgical planning, and impacts management 1.
Key Considerations
The treatment approach should be based on symptom severity, desire for pregnancy, and side effect profiles. Endometriosis works through estrogen-dependent inflammation and tissue growth outside the uterus, which is why hormonal treatments that suppress estrogen or stabilize hormone levels are effective in controlling the condition. The goal of treatment is to improve quality of life and reduce morbidity and mortality, and the most recent evidence should be used to guide treatment decisions 1.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION Therapy with norethindrone acetate tablets must be adapted to the specific indications and therapeutic response of the individual patient. ... Endometriosis Initial daily dosage of 5 mg norethindrone acetate tablets for two weeks. Dosage should be increased by 2. 5 mg per day every two weeks until 15 mg per day of norethindrone acetate tablets is reached. INDICATIONS AND USAGE Norethindrone Acetate Tablets, USP are indicated for the treatment of secondary amenorrhea, endometriosis, and abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology, such as submucous fibroids or uterine cancer.
The treatment option for endometriosis is norethindrone acetate tablets, with an initial daily dosage of 5 mg for two weeks, increasing by 2.5 mg per day every two weeks until 15 mg per day is reached, as needed and as tolerated 2. Norethindrone acetate tablets are indicated for the treatment of endometriosis 2.