What are the treatment options for endometriosis?

Treatment of Endometriosis

First-Line Treatment: NSAIDs and Hormonal Therapy

Start with NSAIDs for immediate pain relief, then initiate combined oral contraceptives or progestins as first-line hormonal therapy—these are equally effective and have superior safety profiles compared to more aggressive options. 1, 2

NSAIDs

• Use at appropriate doses and schedules for immediate pain relief in all patients with endometriosis-related pain 1, 2
• Effective for relieving dysmenorrhea and inflammatory pain 3, 4

Combined Oral Contraceptives (COCs)

• Equally effective as GnRH agonists for pain control while causing far fewer side effects 2
• Provide effective pain relief compared to placebo with mean pain reduction of 13-17 points on a 0-100 visual analog scale 5
• Benefits include low cost, minimal side effects, and widespread availability 2
• Can be used continuously to avoid menstrual cycling 2

Progestins

• Demonstrate similar efficacy to oral contraceptives in reducing pain and lesion size 2
• Available through multiple routes of administration (oral, injectable, intrauterine) 3, 4
• Norethindrone acetate specifically: Start at 5 mg daily for 2 weeks, then increase by 2.5 mg every 2 weeks until reaching 15 mg daily, maintaining this dose for 6-9 months 6

Important First-Line Considerations

• Approximately 11-19% of patients have no pain reduction with hormonal medications 5
• 25-34% experience recurrent pelvic pain within 12 months of discontinuing hormonal treatment 5
• No medical therapy eradicates endometriosis lesions completely—treatment is suppressive, not curative 1, 2

Second-Line Treatment: GnRH Agonists and Danazol

When first-line therapies fail, are not tolerated, or are contraindicated, escalate to second-line options.

GnRH Agonists

• Must be used for at least 3 months to provide significant pain relief 1, 2, 7
• Add-back therapy is mandatory for long-term use to reduce bone mineral loss without compromising pain relief efficacy 1, 2, 7
• Not orally available and have less favorable tolerability profiles compared to first-line options 3, 4

Danazol

• Equally effective as GnRH agonists when used for at least 6 months 1, 2, 7
• Use is limited by availability of better-tolerated hormonal drugs 4

Third-Line Treatment: Aromatase Inhibitors

• Reserved only for women with symptoms refractory to other conventional therapies 2, 4
• Should be administered only in a clinical research setting due to limited long-term efficacy and safety data 3, 4

Surgical Management

Indications for Surgery

• When medical treatment is ineffective, contraindicated, or for severe endometriosis 1, 2
• Medical treatment alone may not be sufficient for severe disease 1, 2, 7
• Surgical excision by a specialist is considered the definitive treatment 2

Surgical Approach

• Laparoscopic excision is preferred over laparotomy unless pelvic or abdominal organ involvement cannot be safely managed laparoscopically 2
• Preoperative MRI pelvis is recommended to map disease extent, identify deep infiltrating lesions, and plan surgical approach 2
• Bowel resection should be performed when necessary to achieve complete disease removal 2
• Bladder endometriosis requires partial cystectomy with complete excision 2

Surgical Outcomes and Limitations

• 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 5
• 10% undergo additional surgery after hysterectomy to treat pain 5

Definitive Surgery

• Hysterectomy with bilateral salpingo-oophorectomy remains the definitive approach for completed childbearing 2
• Should be considered when initial medical and conservative surgical treatments are ineffective 5

Special Population Considerations

Postmenopausal Women

• HRT with estrogen is not contraindicated following hysterectomy and bilateral salpingo-oophorectomy for endometriosis 1, 2, 7
• Combined estrogen/progestogen therapy can treat vasomotor symptoms and may reduce risk of disease reactivation 1
• Postmenopausal women with endometriomas are at higher risk of malignant transformation and require vigilant monitoring 1, 7

Women Seeking Pregnancy

• Medical treatment does not improve future fertility outcomes 2
• Hormonal suppression should not be used in women actively seeking pregnancy 2

Critical Pitfalls to Avoid

• Never use long-term GnRH agonist therapy without add-back therapy—this causes significant bone mineral loss 1, 2, 7
• Pain severity correlates poorly with laparoscopic appearance but correlates with lesion depth 2
• Diagnosis is often delayed 5-12 years after symptom onset, with most women consulting 3 or more clinicians prior to diagnosis 5
• Normal physical examination and imaging do not exclude the diagnosis 5
• Superior hypogastric nerve blocks are unproven with insufficient evidence and should not be used for endometriosis-related pain 2

Complementary Approaches

• Heat application to abdomen or back may reduce cramping pain 1
• Acupressure on specific points may help reduce pain 1
• Aromatherapy with lavender may increase satisfaction and reduce pain or anxiety 1