Treatment of Endometriosis with Concurrent Uterine Fibroids
For patients with both endometriosis and uterine fibroids, initiate medical management first with hormonal therapy targeting both conditions, reserving surgery for refractory cases or when fertility preservation requires definitive intervention. 1, 2
Initial Medical Management Strategy
Start with combined hormonal contraceptives or progestins as first-line therapy, as these agents effectively address both endometriosis-related pain and fibroid-associated bleeding symptoms. 3, 1, 4
Specific Medical Options:
Oral contraceptives provide effective pain relief for endometriosis while reducing menstrual bleeding from fibroids, with lower cost than alternative regimens 3, 4
Norethindrone acetate is FDA-approved for both endometriosis and abnormal uterine bleeding due to fibroids, dosed at 5 mg daily initially for endometriosis, increasing by 2.5 mg every two weeks up to 15 mg daily for 6-9 months 5
Levonorgestrel-releasing IUD effectively controls bleeding symptoms from fibroids and provides long-term management of endometriosis pain 4, 2
Tranexamic acid serves as the preferred nonhormonal option for bleeding control if hormonal therapy is contraindicated 1, 4
Second-Line Medical Therapy:
GnRH agonists or oral GnRH antagonists should be considered when first-line therapies fail, as they reduce both endometriosis lesions and fibroid volume by 18-30%. 3, 1, 6
Mandatory add-back therapy with low-dose estrogen and progestin must be used to prevent bone loss and hypoestrogenic symptoms while maintaining efficacy 3, 1
Treatment duration of at least 3 months for GnRH agonists demonstrates equivalent efficacy to 6 months of danazol 3
Critical limitation: Fertility is suppressed during GnRH therapy and symptoms typically recur rapidly after discontinuation 1, 6
Surgical Management Algorithm
The surgical approach depends critically on three factors: fertility desires, symptom severity after failed medical management, and fibroid location. 1, 2
For Patients Desiring Future Fertility:
Laparoscopic or open myomectomy combined with excision of endometriosis lesions is the primary surgical option when medical management fails. 1, 2
Hysteroscopic myomectomy is specifically indicated for submucosal fibroids <5 cm, offering shorter hospitalization and faster recovery with equivalent symptom improvement at 2-3 months 3, 4
Open myomectomy is preferred over laparoscopic approaches when multiple fibroids are present or the uterus is very large 2
Surgery for endometriosis provides significant pain reduction in the first 6 months, though 44% experience symptom recurrence within one year 3
Fertility outcomes are modest: less than half of patients attempting conception after myomectomy achieve pregnancy, and less than half of these result in live birth 2
For Patients Not Desiring Future Fertility:
Hysterectomy with excision of endometriosis lesions provides definitive resolution with patient satisfaction rates up to 90%. 1, 2
This is the most effective treatment when childbearing is complete and less invasive options have failed 1, 4
Hormone replacement therapy with estrogen is not contraindicated following hysterectomy and bilateral salpingo-oophorectomy for endometriosis 3
Minimally Invasive Alternative:
Uterine artery embolization (UAE) is particularly appropriate for patients with concurrent adenomyosis and fibroids who desire uterus preservation. 1, 2
UAE improves symptoms and quality of life for up to 7 years with a 7% reintervention rate 1
Treatment failure rates are higher (23%) in patients under 40 years due to collateral vessel recruitment 2
Special Clinical Scenarios
Concurrent Adenomyosis:
Medical management or UAE are the preferred initial approaches when adenomyosis coexists with fibroids and endometriosis, as hysteroscopic myomectomy alone is unlikely to provide adequate symptom relief. 3, 1, 2
Severe Endometriosis:
Medical treatment alone may not be sufficient for severe disease, requiring surgical intervention regardless of fibroid management strategy. 3
Preoperative Optimization:
Correct anemia before elective surgery using GnRH agonists/antagonists or selective progesterone receptor modulators with concurrent iron supplementation. 1
Critical Pitfalls to Avoid
Do not expect medical therapy to eradicate endometriosis lesions—no medical therapy has proven to eliminate lesions, only reduce symptoms temporarily 3
Do not assume treatment affects future fertility—there is no evidence that medical treatment of endometriosis improves fertility outcomes 3
Do not perform endometrial ablation in patients desiring fertility preservation, as it carries high risk of pregnancy complications 3
Recognize the high recurrence rate: up to 44% of patients experience symptom recurrence within one year after surgery for endometriosis 3
Expectant management may be appropriate in asymptomatic patients, as endometriosis can be unpredictable and may regress spontaneously 3