Recommended Treatment for Endometriosis
Start with NSAIDs for immediate pain relief combined with continuous combined oral contraceptives or progestins as first-line hormonal therapy, escalating to GnRH agonists with mandatory add-back therapy only if first-line treatments fail, and reserve surgical excision by a specialist for severe disease or when medical management is ineffective. 1, 2
First-Line Medical Management
NSAIDs should be initiated immediately using naproxen 550 mg twice daily or ibuprofen 600-800 mg three times daily for pain control. 1
Hormonal therapy options for first-line treatment include:
Combined oral contraceptives (COCs) are equally effective as GnRH agonists for pain control while causing far fewer side effects, with benefits including low cost, minimal side effects, and widespread availability. 3, 1 Women with endometriosis can safely use COCs without concern for worsening their condition (Category 1 - no restrictions per U.S. Medical Eligibility Criteria). 4
Continuous dosing of oral contraceptives is preferred over cyclic dosing for superior symptom control. 3, 1
Progestins (oral or depot medroxyprogesterone acetate) demonstrate similar efficacy to oral contraceptives in reducing pain and lesion size. 3, 4 The 52mg levonorgestrel-releasing intrauterine system is also recommended as first-line treatment. 5
All hormonal treatments (COCs, progestins, GnRH agonists) lead 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, with little difference in effectiveness among options. 2
Second-Line Medical Management (When First-Line Fails)
GnRH agonists should be reserved for refractory cases using leuprolide 3.75 mg intramuscularly monthly or 11.25 mg every 3 months for at least 3 months. 1, 4
Mandatory add-back therapy with norethindrone acetate 5 mg daily must be prescribed simultaneously to prevent bone mineral loss without reducing pain relief efficacy. 3, 1
Danazol for at least 6 months shows equivalent efficacy to GnRH agonists in reducing pain (Level A evidence), though it is less commonly used due to side effects. 3
Surgical Management
Surgery should be considered when:
- Medical treatment is ineffective, contraindicated, or not tolerated 1, 2
- Severe endometriosis is present where medical treatment alone may not be sufficient 4
- Organ damage is present or suspicious lesions require evaluation 6
Preoperative imaging is essential:
- Obtain high-quality MRI pelvis to map disease extent and identify deep infiltrating lesions (92.4% sensitivity, 94.6% specificity for intestinal endometriosis). 1
- Transvaginal ultrasound by an expert is 97% sensitive and 96% specific for rectovaginal endometriosis. 1
- Preoperative imaging reduces morbidity and mortality by decreasing incomplete surgeries and need for repeat procedures. 3, 1
Surgical approach:
- Laparoscopic approach is recommended over laparotomy. 5
- Surgical excision by a specialist is the definitive treatment, though medical therapies cannot eradicate the disease completely. 3
Postoperative Management
After surgery, hormonal suppression should be continued with a COC or 52mg levonorgestrel-releasing IUS when pregnancy is not desired to prevent recurrence. 1, 5
- Up to 44% of women experience symptom recurrence within one year after surgery. 3, 4
- Cumulative recurrence rates are 10% per postoperative year without medical suppression. 1
- Approximately 25% of patients who undergo hysterectomy for endometriosis experience recurrent pelvic pain and 10% undergo additional surgery. 2
Definitive Surgical Treatment for Completed Childbearing
Hysterectomy with bilateral salpingo-oophorectomy is the definitive approach for women who have completed childbearing and failed other treatments. 3
- If hysterectomy is performed without oophorectomy, ongoing medical suppression may still be required as residual ovarian function can stimulate remaining endometriotic tissue. 3
- Hormone replacement therapy with estrogen is not contraindicated following hysterectomy and bilateral salpingo-oophorectomy for endometriosis. 3, 1, 4
Critical Pitfalls to Avoid
No medical therapy eradicates endometriosis lesions completely - all treatments provide symptom control rather than cure. 1
Medical treatment does not improve future fertility outcomes and hormonal suppression should not be used in women actively seeking pregnancy. 3, 1, 5
Pain severity correlates poorly with laparoscopic appearance but correlates with lesion depth - minimal visible disease can cause severe symptoms. 1
11% to 19% of individuals have no pain reduction with hormonal medications and 25% to 34% experience recurrent pelvic pain within 12 months of discontinuing hormonal treatment. 2
The real choice is not between medical treatment and surgery alone but between medical treatment alone versus surgery plus postoperative medical treatment, as surgery does not cure endometriosis. 6