Endometriosis is a chronic disease. In that sense, there is no cure for endometriosis, but the symptoms can be reduced with the right treatment. Communication is the key to finding a treatment that fits you. Please discuss your options with your doctor and ask any questions you may have. Your doctor will be happy to explain the different options and answer your questions.
Women with endometriosis have either pain, fertility problems or they have both. Treatment of endometriosis focuses on resolving or reducing pain due to endometriosis or on improving fertility, so a patient can get pregnant naturally or through fertility treatments. For treating endometriosis, the doctor can prescribe medical treatment or advise surgical treatment. Both will be explained in detail here.
Depending on the patient, the treatment will be different. Your doctor will take several factors into consideration when prescribing medical treatment or advising surgical treatment. These factors include:
The preferences of the woman
The type of disease (peritoneal disease, ovarian cyst or deep endometriosis)
The severity and type of pain symptoms
The wish to become pregnant immediately or at a later stage
The costs and side-effects of some treatments
The age of the woman
The treatments she has already received.
The doctor (country, expert centre)
This means that two women with endometriosis could receive different treatments and even that one woman could receive different treatments over time depending on her preferences, her age, her wish to become pregnant.
Important to remember is that medical treatment works only when they are taken as prescribed. Stopping medical treatment often means that the symptoms recur.
In the next section, options for medical treatment and surgical treatment will be explained.
When the doctor suspects a woman to have endometriosis related pain, the patient and the doctor can decide that without a definite diagnosis (made by a laparoscopy) the pain is treated as if the patient has endometriosis. This is called empirical treatment or treatment without a definitive diagnosis.
For painful symptoms suspected to be caused by endometriosis, empirical treatment includes analgesia, hormonal contraceptives or progestagens.
Since GnRH analogues have considerable side effects and are very expensive, doctors and patients should consider not using this type of drugs for empirical treatment.
Analgesics, like non-steroidal anti-inflammatory drugs (NSAIDs), are medical therapies that influence how the body experiences pain. These therapies are not specific for endometriosis-associated pain, and they do not alter any disease mechanism in the body like the hormonal treatments do. Analgesics have little side effects, they are cheap, easily accessible and widely used, but very little studies have investigated whether they actually help in reducing endometriosis-associated pain. Long-term use of NSAIDs can be associated with side effects affecting the stomach. Therefore, protection of the stomach is advisable.
Anyway, from clinical experience, the guideline development group recommends that clinicians should consider NSAIDs or other analgesics to reduce endometriosis-associated pain.
Medical treatments for endometriosis include hormonal treatments or pain medication (analgesics).
Hormonal treatments in clinical use are:
- hormonal contraceptives(cyclical use or continuously)
- progestagens (oral or in an Intra Uterine Device)
- GnRH agonists
- aromatase inhibitors
Medical treatment in endometriosis is focussed on resolving pain. Medical treatment should not be prescribed to improve fertility.
In general, medical treatments can help to reduce pain symptoms in women with endometriosis. Which type of medication fits best to an individual patient depends on the complaints, the efficacy and side effects of the treatment and the preferences of the patient.
Another factor is the cost and availability of a certain treatment. In some countries within Europe, some treatments are not available, they are very expensive, or they are not reimbursed. This information can also influence the decision for a certain treatment
Endometriosis is a problem associated with a woman’s menstrual cycle and dependent on the activity of estrogens.
The aim of hormonal treatment for pain in women with endometriosis is lowering the estrogen level. It is important to know that hormonal treatment does not cure endometriosis. Hormonal treatment suppresses the activity of the disease and hence the pain symptoms. However, after discontinuation of the treatment symptoms tend to recur. It is not known which patients will have a relapse of pain symptoms.
Hormonal contraceptives are widely used for contraception and generally accepted. They contain low doses of hormones (estrogen and progesterone) and can reduce pain associated with endometriosis by stopping follicular growth and hence reducing the production and concentration of estrogens. Low estrogens stop the activity of the growth of the endometrium in and outside the uterus, and thus pause endometriosis. The progesterone in the pill decreases the activity of the endometrium directly.
The side effects are limited and hormonal contraceptives are not expensive. Your doctor can prescribe different types of hormonal contraceptives:
- the oral contraceptive pill (taken with or without a monthly pill-free week),
- a vaginal contraceptive ring, or
- a transdermal patch.
Progestagens can be used in different forms: orally, as a 3-monthly injection or a levonorgestrel-releasing intrauterine system. Different types of progestagens are medroxyprogesterone acetate (MPA), dienogest, cyproterone acetate or danazol. Progestagens are also used as contraceptives, but they only contain progesterone, not estrogen. Anti-progestagens (gestrinone) have a similar method of action. Progestagens are relatively inexpensive.
The different types of progestagens and anti-progestagens have different side effects. Doctors are recommended to take the side effects into account when prescribing this type of medication and discuss them with the patient. Patients are recommended to report any side effects with their doctor and discuss their options.
A levonorgestrel-releasing intrauterine system is a small device that is inserted in the uterus and releases low levels of progesterone. A levonorgestrel-releasing intrauterine system is frequently used for contraception; it has limited side effects and is user-friendly. In women with endometriosis, the levonorgestrel-releasing intrauterine system is an option for reducing symptoms of pain.
GnRH agonists induce a very low estrogen level by stopping the follicular growth in the ovary completely. GnRH agonists can be taken intranasal, or through subcutaneous injection as a depot working either one or three months. Some of the most common GnRH agonists are nafarelin, leuprolide, buserelin, goserelin and triptorelin. GnRH agonists have more side effects than oral contraceptives and progestagens and are more expensive.
The side effects of GnRH agonists are related to the low level of estrogens and are comparable to the consequences of the menopausal status. These so-called hypo-estrogenic symptoms are hot flushes and night sweats, vaginal dryness and related pain during intercourse, and influences on the mental health up to depressive feelings. In the long term GnRH agonists are associated with osteoporosis. To reduce these symptoms, clinicians are recommended to prescribe hormonal add-back therapy as soon as GnRH agonists are started. Hormonal add back means adding a combination of estrogens and progesterone (oral contraceptives). This add back therapy takes away the side effects while the therapeutic effect is maintained. Since adolescents and young women up to the age of 23 have not reached their optimal bone density, it is advisable not to use GnRH agonists in these women.
Aromatase inhibitors stop an enzyme (aromatase) that is needed in the production of estrogens in several cells of the body. The result is a very low estrogen level. These drugs have been used in other diseases, but they are only recently been used in endometriosis and not well studied yet.
Due to the side effects (vaginal dryness, hot flushes, diminished bone mineral density), aromatase inhibitors should only be prescribed to women in severe pain after trying all other options of medical and surgical treatment.
Aromatase inhibitors are not available in some European countries
Since the aim of treatment in endometriosis-associated pain is lowering the level of estrogens, the side effects are related to a low estrogen level. Besides that, the side effects are related to the drugs used to reach that low estrogen level.
Side effects are therefore related either to low estrogens (hormonal contraception, GnRH analogues) or to progesterone (hormonal contraception, progestagens).
Some examples of side effects of hormonal treatment for pain in endometriosis are headaches, acne, weight gain, vaginal spotting, fatigue and hot flushes.
These side effects differ strongly between treatments and between patients. As a result, a certain treatment can be a good option for one woman, but the same treatment can have severe side effects in another woman. Your doctor should discuss side effects with you when prescribing hormonal treatment.
Surgical treatment of endometriosis focuses on the elimination of peritoneal endometriosis/endometrioma/deep endometriosis and division of adhesions.
In the past, open surgery or laparotomy was used routinely. Nowadays, laparoscopy is used frequently and preferred since it usually results in less pain, shorter hospital stay, quicker recovery and a smaller scar. However, laparotomy and laparoscopy are equally effective in treating pain symptoms in women with endometriosis.
Therefore, clinicians should consider surgical treatment (elimination of endometriotic lesions) when they see endometriotic lesions during laparoscopy for diagnosis.
If deep endometriosis is suspected, doctors are recommended to refer their patient to a centre of expertise, as these surgeries may be difficult.
If a woman has completed her family and other treatments do not work, removal of the ovaries with or without removal of the uterus (hysterectomy) can be considered. However, removal of the ovaries is a radical solution, since it results in so called surgical menopause with the side effects of menopause described above. It has to be mentioned that hysterectomy alone not always solves the problem, since most of the time endometriosis is left behind retroperitoneally and hence the pain symptoms remain present.
There is some controversy on this subject.
The guideline group does not recommend hormonal treatment before surgery to improve the results of the surgery. Of course, many women in pain get hormonal treatment during a waiting period before surgery. After surgery, starting with an oral contraceptive pill or using a levonorgestrel-intrauterine device may prevent recurrence of pain.