Treatment of Endometriosis
First-Line Medical Management
Start with NSAIDs for immediate pain relief (naproxen 550 mg twice daily or ibuprofen 600-800 mg three times daily), followed immediately by continuous combined oral contraceptives or progestins as first-line hormonal therapy. 1
Combined oral contraceptives used continuously 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. 2, 1
Progestins (such as norethindrone or depot medroxyprogesterone acetate) demonstrate similar efficacy to oral contraceptives in reducing pain and lesion size, though neither eradicates endometriosis completely. 2, 1
In a network meta-analysis of 1,680 patients across 15 trials, hormonal treatments including combined oral contraceptives, progestins, and GnRH agonists led to clinically significant pain reduction compared with placebo, with mean differences ranging between 13.15 and 17.6 points on a 0-100 visual analog scale. 3
The levonorgestrel intrauterine device is particularly effective at relieving dysmenorrhea and pain from rectovaginal endometriosis lesions. 4
Second-Line Medical Management
Reserve GnRH agonists for cases where first-line therapies fail, using leuprolide 3.75 mg intramuscularly monthly or 11.25 mg every 3 months for at least 3 months. 1
Mandatory add-back therapy with norethindrone acetate 5 mg daily must be prescribed simultaneously to prevent bone mineral loss without reducing pain relief efficacy. 2, 1
GnRH agonists induce a pseudomenopausal state with significant side effects including hot flashes and genital atrophy, which are mitigated by add-back therapy. 4
Oral GnRH antagonists are effective alternatives for reducing bleeding symptoms. 1
Danazol for at least 6 months shows equivalent efficacy to GnRH agonists in reducing pain, though it is less commonly used due to androgenic side effects. 2
Surgical Management
Surgical excision by a specialist is the definitive treatment when medical therapy is ineffective, contraindicated, or for severe disease, but must be followed by postoperative medical suppression. 2, 1, 3
Obtain high-quality preoperative MRI pelvis to map disease extent and identify deep infiltrating lesions (92.4% sensitivity and 94.6% specificity for intestinal endometriosis), as preoperative imaging reduces morbidity and mortality by decreasing incomplete surgeries and need for repeat procedures. 2, 1
Transvaginal ultrasound is 97% sensitive and 96% specific for rectovaginal endometriosis and 80% sensitive and 97% specific for uterosacral ligament implants. 1
Laparoscopic approaches are preferred over laparotomy for conservative treatment via excision or ablation of lesions. 5
For ovarian endometriomas, perform cystectomy rather than fenestration or fulguration, though be aware of potential decreases in ovarian reserve. 5
Postoperative medical suppressive therapy is strongly recommended to prevent cumulative symptom and lesion recurrence rates of 10% per postoperative year. 1, 5, 6
Definitive Surgical Options for Completed Childbearing
Hysterectomy with bilateral salpingo-oophorectomy combined with complete excision of all visible endometriosis lesions is the definitive approach for women who have completed childbearing. 2, 1
If hysterectomy is performed without oophorectomy, ongoing medical suppression may still be required as residual ovarian function can stimulate remaining endometriotic tissue. 2
Bilateral oophorectomy should be carefully considered, as this leads to premature surgical menopause and may not decrease the possibility of reoperation in patients aged 30-39 years. 5
Hormone replacement therapy with estrogen is not contraindicated following hysterectomy and bilateral salpingo-oophorectomy for endometriosis. 2, 1
Approximately 25% of patients who undergo hysterectomy for endometriosis experience recurrent pelvic pain and 10% undergo additional surgery. 3
Critical Pitfalls to Avoid
No medical therapy eradicates endometriosis lesions completely—all treatments provide symptom control rather than cure. 1, 6
Up to 44% of women experience symptom recurrence within one year after surgery, and 25-34% experience recurrent pelvic pain within 12 months of discontinuing hormonal treatment. 2, 1, 3
Medical treatment does not improve future fertility outcomes, and hormonal suppression should not be used in women actively seeking pregnancy. 2, 1
Pain severity correlates poorly with laparoscopic appearance but correlates with lesion depth, meaning minimal visible disease can cause severe symptoms. 1
Between 11-19% of individuals with endometriosis have no pain reduction with hormonal medications. 3
The real choice is not between medical treatment and surgery, but between medical treatment alone and surgery plus postoperative medical treatment, as surgery does not cure endometriosis. 6
Adjunctive Non-Pharmacologic Measures
Heat application to the abdomen or back may reduce cramping pain. 1
Acupressure on Large Intestine-4 or Spleen-6 points may help reduce cramping pain. 1
Aromatherapy with lavender may increase satisfaction and reduce pain or anxiety. 1
Consider comprehensive multidisciplinary care including psychologists, sexologists, physiotherapists, dieticians, and pain therapists, as trauma (especially sexual trauma) and pelvic floor disorders can cause or contribute to symptoms. 6