What are the options for pain management in patients with endometriosis?

From the Guidelines

Pain management for endometriosis should prioritize a multi-faceted approach, combining medications and lifestyle modifications, with first-line treatment often including nonsteroidal anti-inflammatory drugs (NSAIDs) and hormonal therapies, as supported by the most recent evidence 1.

Medications for Pain Management

• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (400-800mg every 6-8 hours) or naproxen (500mg twice daily) are effective in reducing inflammation and pain 1.
• Hormonal therapies, including combined hormonal contraceptives (pills, patches, or rings), can be taken continuously to prevent menstruation and associated pain.
• Progestins like norethindrone acetate (5-15mg daily) or medroxyprogesterone acetate can reduce endometrial growth.
• For more severe cases, GnRH agonists such as leuprolide (3.75mg monthly injection) may be prescribed, though these should be limited to 6-12 months due to bone density concerns and are often given with add-back hormone therapy 1.

Lifestyle Modifications

• Heat therapy, regular exercise, dietary changes (reducing inflammatory foods), and stress management techniques can help manage pain.
• Pelvic floor physical therapy may address muscle tension contributing to pain.

Diagnosis and Treatment Approach

• The diagnosis of endometriosis is challenging due to variable presenting symptoms and nonspecific physical examination findings, but expanded protocol transvaginal ultrasound (TVUS) and MRI can help identify and "map" deep endometriosis 1.
• Treatment of endometriosis is variable and largely determined by the patient’s individualized goals, with medical therapies helping to temporize symptoms and surgical excision by a specialist considered the definitive treatment 1.

Key Considerations

• The clinical presentation of endometriosis is variable, ranging from asymptomatic to severe symptoms that interfere with daily activity, and approximately one-half of patients with endometriosis experience infertility 1.
• Health care spending on endometriosis is significant, with an estimated annual economic burden of $69.4 billion 1.
• A combination of these approaches provides the most effective relief while minimizing side effects, as supported by the most recent evidence 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.

• Pain management for endometriosis using norethindrone acetate (PO) involves an initial daily dosage of 5 mg for two weeks, with a gradual increase of 2.5 mg every two weeks until a maximum of 15 mg per day is reached.
• The treatment may be continued for six to nine months or until breakthrough bleeding occurs, requiring temporary termination of therapy 2.

From the Research

Pain Management Options for Endometriosis

• Medical management options include nonsteroidal anti-inflammatory drugs (NSAIDs), oral contraceptives, progestins, and gonadotropin-releasing hormone (GnRH) agonists 3, 4, 5, 6
• Surgical management options include laparoscopic uterosacral nerve ablation/resection, presacral neurectomy, excision/ablation of lesions, nerve ablation, neurectomy, hysterectomy, and oophctomy 3
• Experimental pharmaceuticals such as Gestirone and aromatase inhibitors have shown promise but are still under scrutiny 3, 5, 6
• Oral GnRH antagonists, including elagolix, relugolix, and linzagolix, have been shown to be effective in reducing endometriosis-related pain 7

Efficacy of Pain Management Options

• NSAIDs have been found to have very low-quality evidence for pain relief in women with endometriosis 4
• Oral contraceptives and progestins have been shown to be effective in improving pain symptoms in the majority of patients 5, 6
• GnRH agonists have been found to be efficacious in treating women not responding to oral contraceptives or progestins, but have a less favorable tolerability profile 5
• Oral GnRH antagonists have been shown to be effective in reducing endometriosis-related pain, with a favorable tolerability profile 7

Treatment Strategies

• Initial treatment for endometriosis is often surgical or medical, with medical therapy used as a first-line therapy or in conjunction with surgical therapy for pain 6
• Medical therapy consists mostly of hormonal suppressive therapy, with non-steroidal anti-inflammatory drugs and oral contraceptives often used as an initial approach 6
• New drug therapies, such as aromatase inhibitors and immunomodulators, are under investigation, as well as new delivery systems to improve patient response 6