What are the treatment options for a patient with endometriosis?

Treatment of Endometriosis

First-Line Medical Management

Start with NSAIDs for immediate pain relief, followed by combined oral contraceptives or progestins as first-line hormonal therapy. 1, 2

• Combined oral contraceptives and progestins are equally effective first-line options with superior safety profiles compared to more costly regimens, providing clinically significant pain reduction (13.15-17.6 points on 0-100 visual analog scale) compared to placebo. 1, 2

• Continuous oral contraceptive pills are as effective as GnRH agonists for pain control while causing far fewer side effects, with benefits including low cost, minimal side effects, and widespread availability. 1

• Progestins demonstrate similar efficacy to oral contraceptives in reducing pain and lesion size, though they do not eradicate endometriosis completely. 1

• Medroxyprogesterone acetate injectable (150 mg IM every 3 months) is FDA-approved for contraception and can be used for endometriosis suppression, though bone mineral density loss should be considered with long-term use. 3

Important Limitations of First-Line Therapy

• Approximately 11-19% of patients have no pain reduction with hormonal medications, and 25-34% experience recurrent pelvic pain within 12 months of discontinuing hormonal treatment. 2

• Medical treatment does not improve future fertility outcomes, and hormonal suppression should not be used in women actively seeking pregnancy. 1

• No medical therapy eradicates endometriosis lesions completely—medications induce disease remission but do not cure the disease. 1, 4

Second-Line Medical Management

Reserve GnRH agonists and antagonists for refractory cases when first-line therapies fail. 1, 2

• GnRH agonists for at least 3 months provide significant pain relief when first-line therapies fail, with mandatory add-back therapy (progestin) to prevent bone mineral loss without reducing pain relief efficacy. 1

• Danazol for at least 6 months shows equivalent efficacy to GnRH agonists in reducing pain, with Level A evidence supporting its use. 1

Surgical Management

Surgery should be considered when medical treatment is ineffective, contraindicated, or for severe endometriosis, with laparoscopic excision by a specialist being the definitive treatment. 1, 2, 5

Surgical Approach Algorithm

• Laparoscopic approaches are preferred over laparotomy for conservative treatment via excision or ablation/fulguration of lesions. 5

• For ovarian endometriomas, cystectomy is preferred over fenestration or fulguration, though there may be associated decreases in ovarian reserve. 5

• For deep infiltrating endometriosis involving bowel or bladder, the risks of aggressive surgery must be weighed against clear pain reduction benefits—bowel resection should be performed when necessary to achieve complete disease removal. 1, 5

• Preoperative imaging with MRI pelvis or expanded protocol transvaginal ultrasound reduces morbidity and mortality by decreasing incomplete surgeries and need for repeat procedures. 1, 6

Surgical Outcomes and Limitations

• Up to 44% of women experience symptom recurrence within one year after surgery, highlighting the importance of ongoing management. 1

• Postoperative medical suppressive therapy is strongly recommended to prevent cumulative symptom and lesion recurrence rate of 10% per postoperative year. 5, 4

• Surgery is more successful for severe deep dyspareunia caused by fibrotic lesions infiltrating the posterior compartment, while medications are generally more successful for severe dysmenorrhea. 4

Definitive Surgical Management for Completed Childbearing

Hysterectomy with bilateral salpingo-oophorectomy combined with complete excision of endometriosis lesions remains the definitive approach for patients with completed childbearing. 1

• If hysterectomy is performed without oophorectomy, ongoing medical suppression may still be required as residual ovarian function can stimulate remaining endometriotic tissue. 1

• Bilateral oophorectomy should be given careful consideration, as this procedure leads to premature surgical menopause and may not decrease the possibility of reoperation in patients aged 30-39 years. 5

• Approximately 25% of patients who undergo hysterectomy for endometriosis experience recurrent pelvic pain and 10% undergo additional surgery. 2

• Hormone replacement therapy with estrogen is not contraindicated following hysterectomy and bilateral salpingo-oophorectomy for endometriosis. 1

Third-Line and Adjunctive Therapies

• Aromatase inhibitors are considered third-line treatments for refractory cases. 2, 7

• The levonorgestrel intrauterine device is quite effective at relieving pain associated with endometriosis, especially menstrual pain and pain from rectovaginal lesions. 7

Critical Clinical Pitfalls to Avoid

• Do not assume pain severity correlates with laparoscopic appearance—pain correlates poorly with lesion appearance but does correlate with lesion depth. 1, 6

• Do not delay empiric treatment waiting for surgical confirmation—diagnosis is fundamentally clinical and does not require surgical confirmation before initiating treatment. 6

• Do not overlook that trauma (especially sexual trauma) and pelvic floor disorders can cause or contribute to symptoms in many individuals with chronic pelvic pain—endometriosis may not always be the sole origin of complaints. 4

• Do not use medical therapy to improve fertility outcomes—it is ineffective for this indication. 1