What are the treatment options for a patient with endometriosis?

Endometriosis Treatment

First-Line Medical Management

Start with NSAIDs for immediate pain relief (naproxen 550 mg twice daily or ibuprofen 600-800 mg three times daily) combined with continuous oral contraceptives or progestins as first-line hormonal therapy. 1

• Continuous oral contraceptives 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
• Combined oral contraceptives and progestins demonstrate equal efficacy as first-line options with superior safety profiles compared to more costly regimens 1
• Women with endometriosis can safely use combined oral contraceptives without concern for worsening their condition 1
• Progestins show similar efficacy to oral contraceptives in reducing pain and lesion size 1
• In a network meta-analysis of 1680 patients across 15 trials, hormonal treatments 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

Critical caveat: No medical therapy eradicates endometriosis lesions completely—all treatments provide symptom control rather than cure. 1

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 provide significant pain relief when first-line therapies fail 2, 1
• 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 side effects 2, 1

Important limitation: 11% to 19% of individuals with endometriosis have no pain reduction with hormonal medications, and 25% to 34% experience recurrent pelvic pain within 12 months of discontinuing hormonal treatment. 3

Surgical Management

Surgical excision by a specialist is the definitive treatment when medical therapy is ineffective, contraindicated, or for severe disease. 2, 1, 3

Preoperative Planning

• Obtain high-quality preoperative MRI pelvis to map disease extent and identify deep infiltrating lesions, with 92.4% sensitivity and 94.6% specificity for intestinal endometriosis 1
• Transvaginal ultrasound is 97% sensitive and 96% specific for rectovaginal endometriosis and 80% sensitive and 97% specific for uterosacral ligament implants 1
• Preoperative imaging reduces morbidity and mortality by decreasing incomplete surgeries and need for repeat procedures 2, 1

Surgical Approach

• Laparoscopic approaches are preferred over laparotomy when conservatively treating endometriosis via excision or ablation of lesions 4
• For ovarian endometriomas, cystectomy is preferred over fenestration or fulguration, though there may be associated decreases in ovarian reserve 4
• For deep infiltrating endometriosis, the risks of aggressive bowel surgery must be weighed against the benefits of clear pain reduction 4

Postoperative Management

Postoperative medical suppressive therapy is strongly recommended to prevent cumulative recurrence rates of 10% per postoperative year. 1, 4

• Up to 44% of women experience symptom recurrence within one year after surgery 2, 1
• The real choice is not between medical treatment and surgery, but between medical treatment alone and surgery plus postoperative medical treatment 5

Definitive Surgical Options for Completed Childbearing

Hysterectomy with bilateral salpingo-oophorectomy 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, 1
• Approximately 25% of patients who undergo hysterectomy for endometriosis experience recurrent pelvic pain and 10% undergo additional surgery 3
• Hormone replacement therapy with estrogen is not contraindicated following hysterectomy and bilateral salpingo-oophorectomy for endometriosis 2, 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 to 39 years 4

Critical Clinical Pitfalls

• Pain severity correlates poorly with laparoscopic appearance but correlates with lesion depth, meaning minimal visible disease can cause severe symptoms 1
• Medical treatment does not improve future fertility outcomes, and hormonal suppression should not be used in women actively seeking pregnancy 2, 1
• Treatments should be symptom-oriented rather than lesion-oriented 5
• Medical therapies are generally more successful for severe dysmenorrhea, while surgery is more successful for severe deep dyspareunia caused by fibrotic lesions infiltrating the posterior compartment 5

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