Illustration: Emma Günther
Managing endometriosis: treatment options
Endometriosis is a chronic inflammatory disease, affecting up to 1 in 10 women, and yet treatment options are limited (1). The physical symptoms of endometriosis can be managed, but not cured. Endometriosis symptoms often persist until menopause.
For many people, the symptoms of endometriosis can be managed through different forms of treatment. The most common symptoms of endometriosis are pelvic pain (which can be chronic or cyclic) or dysmenorrhea (painful menstruation). Some people also experience pain during sex, painful urination, or pain when having a bowel movement (1).
Available management options can be hormonal, non-hormonal, and/or surgical, depending on a person's symptoms and goals.
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NSAIDs
NSAIDs (non-steroidal anti-inflammatory drugs) are a group of medications used for treating pain, reducing fever, and reducing inflammation. These medications are available under many different names, formulas, and dosages, including aspirin and ibuprofen. NSAIDs are often available without a prescription and can help to decrease pain, particularly for people who experience mild to moderate symptoms of dysmenorrhea and pelvic pain (2).
For people looking to become pregnant, pain-relief medication may be the most effective form of endometriosis treatment available, since hormonal contraceptives and other hormone-containing medications prevent conception. It’s best to avoid very strong selective NSAIDs if you are trying to get pregnant, as these may disrupt or prevent ovulation (3-5).
Hormone medications
Hormone-containing medications can be used to treat the symptoms of endometriosis. There are many different hormone-containing medications available, all of which are equally effective at managing the symptoms of endometriosis. Hormone treatment should be therefore based on what is safest, most tolerated, and most cost-effect for the individual person (6,7). Hormonal contraceptives are often used and prescribed because they are inexpensive, readily available (in many countries), and are generally well tolerated (6). The only real limiting factor here is if a women is looking to conceive (8).
Combined hormonal contraceptives Hormonal contraceptives containing both estrogen and progestins—such as the most common types of birth control pills, as well as the contraceptives like the hormonal vaginal ring and the patch—are often prescribed to people with endometriosis (6).
Combined hormonal contraceptives can prevent or decrease endometriosis pain by inhibiting ovulation and natural reproductive hormone cycling, as well as by encouraging the shrinking of endometrial-like tissue, promoting the death of endometrial-like tissue outside of the uterus, and impeding endometrial-like tissue proliferation (9,10).
Using hormonal birth control stops the typical growth and shedding of the uterine lining, and the ups-and-downs of hormones which cause proliferation and growth of endometrial-like tissue. This treatment can help to decrease or stop pelvic pain, dysmenorrhea, or excessive menstrual bleeding from endometriosis (11).
Combined hormonal contraceptives can be used to prevent pain from recurring after surgery (which unfortunately doesn’t always work at eliminating pain from endometriosis) (11).
Oral contraceptives can be prescribed in a cyclic administration (taking oral contraceptive pills including the placebo pills or pill-free days, and getting a withdrawal bleed once a month) or as continuous administration (taking active hormonal pills every day thereby not having a monthly withdrawal bleeding (“period”)).
Using hormonal contraceptives in a continuous regime after surgical treatment for endometriosis may be more effective for preventing the recurrence of dysmenorrhea and pelvic pain, by preventing uterine bleeding completely (8,9).
Progestin-only contraceptives Progestin-only contraceptive therapies are also a commonly used treatment option for endometriosis. Progesterone hormonal treatments are particularly popular, as they provide pain relief in 3 out of 4 people (8). Progestin-IUDs are another contraceptive option to help treat the symptoms of endometriosis, including dysmenorrhea and may also promote regression of the disease (12-14).
Hormonal suppression therapy
GnRH agonists and antagonists Medications that block the hormonal pathways between the brain and the ovary are used to prevent the cyclical hormonal changes of the menstrual cycle. These include both gonadotropin releasing hormone (GnRH) agonists and antagonists.
GnRH is a hormone produced in the brain, and helps to signal the ovaries to produce estrogen. These medications stop this signal through the blocking or competitive binding of the GnRH receptors. Without this signal, the ovaries do not make estrogen, a dominant follicle does not form, and ovulation does not happen. Without estrogen, the endometrium (the lining of the uterus) does not grow and proliferate, and neither does the endometrial-like tissue of present outside of the uterus.
These medications put the body into a hypoestrogenic (low estrogen) state, which can come with some fairly harsh side-effects including hot flashes, vaginal dryness, mood swings, and bone mineral loss (12,15). Therapies that “add-back” estrogen to prevent these side effects may be given in conjunction with GnRH agonists (12).
Surgical Treatments
When medications don’t effectively reduce symptoms, surgical procedures to remove endometrial-like tissue become an option. Surgery is often performed laparoscopically. Laparoscopic surgery is a minimally invasive surgery performed through very small cuts in the abdomen or pelvis.
Laparoscopic surgery is used to diagnose endometriosis, as well as to treat it by cutting out (excision) or destruction (ablation) of the endometrial-like tissue. The goals are to treat the structural causes of endometriosis pain by removing or destroying the endometrial-like tissue present outside of the uterus, as well as to repair any damaged organs or tissue caused by endometriosis (16).
When endometriosis is severe and involving multiple organ systems (like the bowels or bladder), more complex and dramatic surgical procedures may be recommended (16).
People with endometriosis often choose to have these surgeries not only to decrease their endometriosis pain, but also to improve fertility if they are struggling to become pregnant. Laparoscopic surgery helps many people with endometriosis by decreasing pain as well as increasing fertility (16).
Other surgeries, nerve ablation or a neurectomy, are available to help quell pain through the destruction of nerve pathways that transmit pain signals from the spine to the pelvis (16). However, these surgeries carry extra risks and do not offer any added benefits in comparison to conventional laparoscopic surgery (11).
A hysterectomy—the surgical removal of the uterus—can be seen as a last resort (1). A hysterectomy can include removing the ovaries or leaving them in place—thereby preventing early onset menopause. The American College of Obstetricians and Gynecologists recommends that hysterectomy should only be a treatment option for people who medical and previous surgical treatments have failed, and who are no longer looking to become pregnant (1).
These surgical treatments are not guaranteed to provide pain relief. After a first laparoscopic surgery, it is very common for people to need additional surgeries later in life (1,17). One study found that after a seven year follow-up, 58% of people who had a previous laparoscopic surgery had undergone reoperative surgery (17). In comparison, people who underwent a hysterectomy but kept their ovaries only had a re-operation rate of 23%, and those who had a full hysterectomy including the removal of their ovaries had only 9% reoperation rate (17).
Alternative or lifestyle treatments
Alternative or complementary treatments for endometriosis are limited. Acupuncture has shown some results at reducing dysmenorrhea associated with endometriosis, but there is not enough research yet to draw firm conclusions (18,19).
While diet and food choices seem to impact many diseases, so far there is very little evidence focused on endometriosis and diet. One study has noted that people who eat more fresh green vegetables and fruit had a reduced risk of having endometriosis, in comparison to people who consumed larger amounts of meat products (20). No differences in endometriosis rates were observed when comparing consumption of coffee, alcohol, milk, or other food products (20). More research is needed.
These treatments and therapies are very complex and not something that you need to navigate alone. Be vocal and clear with your healthcare provider to let them know how your symptoms are improving, and if you are experiencing any side effects. It may take a few attempts to find the right management plan for you.
Download Clue to track pain and heavy menstruation, or create custom tabs to track your individual symptoms.
