Treatment Options for Endometriosis: From Medication to Surgery

Kenneth Barron, MD

Endometriosis, characterized by endometrial-LIKE tissue growing outside the uterus, leads to symptoms like pelvic pain and infertility due to inflammation and scarring on surrounding tissue and organs. While its exact cause remains unclear (there are multiple theories that make biological sense) hormonal factors contribute significantly to its development and progression. Various hormonal treatments aim to suppress estrogen production or alter hormonal activity to alleviate associated pain and discomfort. Unfortunately, there are not currently any FDA approved medications that directly treat endometriosis. As a patient recently pointed out to me--”why aren’t there monoclonal antibodies to treat this disease when they exist for so many other diseases these days?” My answer was I don’t know and there should be!

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Here at the Center for Advanced Gynecology we believe that EARLY diagnosis and treatment are crucial to treating endometriosis effectively and preserving fertility. This means understanding treatment options for both individuals and healthcare providers. Through medical management, surgical interventions, hormone therapy, and lifestyle adjustments, those with endometriosis can actively address their symptoms and preserve their reproductive health.

What are Endometriosis Symptoms?

Endometriosis can cause a wide range of symptoms. One of the main signs is dysmenorrhea, which means VERY painful periods. But with endometriosis, pelvic pain can linger all month, making it hard to do normal everyday things. The severity of these symptoms can vary a lot, from mild annoyance to debilitating pain leading to nausea and vomiting.

Pain during sex, known as dyspareunia, is another common symptom that can strain relationships and lead to emotional distress. Infertility is another big worry for many, leading them to try different treatments like hormone therapy or surgery to increase their chances of having a baby.

On top of all this, endometriosis can also cause fatigue, intestinal issues, and urinary problems-- all of which need careful management.

How to Treat Endometriosis

When you're dealing with endometriosis, it’s important for your treatment plan to be tailored for you. Everyone experiences different symptoms, has unique concerns and personal goals. We consider things like how severe your symptoms are, where the endometriosis may be located, and whether you are actively trying for children, to create a plan that’s best for you.

The main goals of treating endometriosis are generally treating pain, infertility or both. As I’ve said, treatment depends on an individual’s goals. Generally, we believe that surgical excision is the basis of treatment. However, there is a recurrence risk even with the most aggressive surgery. Therefore, if tolerated, hormonal medications are recommended after surgery. For some patients hormonal medications are appropriate with the goal of stopping cyclical hormonal fluctuations and menstruation to decrease the chance of recurrence of disease or pain. Slowing down the disease's progression is also important to prevent further issues like adhesions and scarring in your pelvis if surgery is being postponed.

Hormone medications work to balance the hormones that can stimulate endometriosis tissue to grow and become inflamed, helping to keep the disease in check. Unfortunately, hormone medications don’t work all of the time because some proportion of endometriosis disease can create its own estrogen supply.

Medication Options

When exploring medication options for managing endometriosis, we consider various pharmaceutical interventions tailored to address specific symptoms and concerns. These medications aim to alleviate pain, suppress disease activity, improve fertility, and improve overall quality of life.

Birth Control Pills

Birth control pills, often the first line of defense against endometriosis, help regulate your hormones: instead of cyclic fluctuation in estrogen and progesterone, these levels are kept steady throughout the month which has been shown to help pain symptoms in a majority of women.2 These pills stop ovulation and change your menstrual cycle, which lowers estrogen production. Since estrogen can cause endometriosis tissue to grow outside the uterus, reducing it can ease symptoms like pelvic pain, painful periods, and pain during sex.

However, birth control pills can also have side effects, such as nausea, breast tenderness, headaches, irregular bleeding, mood changes, or weight fluctuations. AND they don’t always work!

Gonadotropin-releasing hormone (GnRH) Modulators

Gonadotropin-releasing hormone (GnRH) modulators are another class of medications used in the treatment of endometriosis. They work by suppressing the production of estrogen and progesterone, inducing a state of temporary menopause. By reducing hormonal stimulation, GnRH agonists can shrink endometrial implants, alleviate pain, and temporarily stop the progression of the disease. They are often prescribed for individuals with severe symptoms, those who have not responded to other forms of treatment, or those planning In-Vitro Fertilization (IVF).

Despite being effective for a high percentage of women, GnRH modulators might cause adverse effects like hot flashes, vaginal dryness, mood changes, depression, joint pain, weight gain, loss of libido. Prolonged use can also heighten the risk of bone loss, osteoporosis and resultand fractures. Lastly, there is a limited duration of use according to FDA approval for these medications from 6 months to 2 years maximum. While we rarely use these medications in our practice, your doctor might recommend short-term use in preparation for surgery, to reduce the risk of needing to remove an ovary during surgery, or in preparation for fertility treatment. You should always consult with your doctor about the risks and benefits before starting treatment.

Progestin Therapy

Progestins, which are synthetic versions of the hormone progesterone, are often used to manage endometriosis hormonally. These are first line agents at the Center for Advanced Gynecology.  These medications work by stopping ovulation and thinning the lining of your uterus, which can shrink endometriosis implants and eases symptoms.3-6 Depending on what you prefer and your treatment goals, your doctor might suggest taking progestins as oral pills, using an intrauterine device (IUD), or getting injections. Common progestins are norethindrone, drospirenone, or micronized progesterone.

While many people handle progestin therapy well, it can still cause side effects like irregular bleeding, weight changes, and mood swings. You might also experience breast sensitivity or acne. It's important to talk with your doctor about these potential side effects and work together to choose the best form of progestin therapy that fits your needs and preferences.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs are commonly employed to alleviate pain associated with endometriosis. They work by reducing inflammation and blocking the production of prostaglandins, chemicals that contribute to pain and inflammation. NSAIDs can help alleviate symptoms such as pelvic pain, dysmenorrhea, and dyspareunia, improving quality of life. They also can reduce how heavy periods are when taken around the clock (every 6-8 hours) from the first day of your cycle.7

NSAIDs offer effective short-term pain relief but can pose risks with long-term use, such as gastrointestinal irritation, ulcers, and kidney damage. Your doctor might suggest limiting their use duration or combining them with other pain management methods to reduce adverse effects.

Anti-Inflammatory Supplements

Anti-inflammatory supplements may improve painful periods and also improve gastro-intestinal symptoms related to endometriosis. There is limited evidence for the effectiveness of N-Acetyl-Cysteine(NAC)8 and N-Palmitoylethanolamine (PEA)-transpolydatin9. Unfortunately, there is not convincing evidence that vitamins C, D, E or Omega-3 supplements are more effective than placebo.10

Surgical Options

We believe in surgery for endometriosis. The timing of surgery, however, is different for each individual. Surgery is often a key part of treating endometriosis, especially when medications and diet changes haven't worked well enough to relieve symptoms or control the disease progression. Surgery, however, is not considered curative. There is a recurrence rate even with the most aggressive surgery. The best data indicates a recurrence of 20% at 2 years and 50% at 5-7 years with excision surgery.11

This decision is something you and your doctor will make together, ensuring the chosen approach aligns with your health needs and personal preferences.

Laparoscopy

Laparoscopy, often known as minimally invasive surgery, is a common method for treating endometriosis. During this procedure, a surgeon uses a thin, lighted instrument called a laparoscope, which is inserted through small cuts in your abdomen. This allows the surgeon to see and treat endometrial implants and adhesions directly in a magnified way. In our opinion, this is the only way endometriosis surgery should be done as there is never a need for a laparotomy in skilled hands.

Benefits of laparoscopy include shorter recovery times, less postoperative pain, and a lower risk of complications compared to traditional open surgery.

While laparoscopy is usually very effective, it does carry some risks like bleeding, infection, and the possibility of injuring nearby organs, although these complications are rare. You might also feel some temporary discomfort or bloating after the surgery. Recovery times can vary, depending on the extent of the surgery and your personal health factors, but most patients can get back to their normal activities within 2 weeks.

Laparotomy

During a laparotomy, your doctor might make a larger incision in your abdomen to access and remove visible endometriosis tissue and address any complications. A skilled endometriosis surgeon should almost never need to use this type of surgery.

Hysterectomy

A hysterectomy, which involves surgically removing the uterus (not the ovaries), is seen as a the last resort for those with severe symptoms of endometriosis that haven’t responded to other treatments. While it effectively stops menstrual periods and can provide long-term relief from pelvic pain there are some long term risks. Studies have shown lower rates of recurrent pain when a hysterectomy is done in conjunction with endometriosis excision.11,12  The average age of menopause is about 3 years earlier after a hysterectomy, there is a small chance of ovarian failure after a hysterectomy, and there may be a small increased risk of vaginal prolapse.
That being said there are several situations where a hysterectomy can be recommended:

• Adenomyosis
• Fibroids that are causing symptoms
• Previous conservative surgery has not been effective
• Conservative surgery is not feasible due to the severity of disease
• Some of your pain is thought to be uterine-derived

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If you're considering a hysterectomy, it's important to have a detailed discussion with your doctor about your concerns, what you hope to achieve, and all available treatment options. This option might be suitable if you've finished having children or if preserving fertility isn't a priority for you, but it's vital to carefully weigh the potential benefits against the risks and long-term effects.

Understanding how it might affect your hormonal balance, possibly lead to menopausal symptoms, and impact your long-term health is crucial, and you should discuss strategies for managing these issues with your healthcare provider.

Endometriosis Pain Management Strategies

Endometriosis pain can really affect your daily life and well-being. While medical treatments like hormonal therapies and surgeries are key in managing symptoms, there are also complementary methods that can help ease your pain and improve your overall quality of life.

Heat Therapy

Using heat therapy, like heating pads or warm baths, can be a simple yet effective way to relieve the pelvic pain that comes with endometriosis. Heat increases blood flow to the pelvic area, relaxes muscles, and reduces tension, which can provide temporary relief from discomfort. Many find heat therapy especially helpful during menstruation or intense pain episodes, offering a non-invasive and drug-free way to manage symptoms.

Pelvic Floor Exercises

Pelvic floor exercises, often known as Kegel exercises, help strengthen and enhance the resilience of your pelvic floor muscles, improving stability, flexibility, and functionality. These exercises can decrease pelvic pain and discomfort linked to endometriosis, and they also help with bladder and bowel control, reduce tension and spasms in the pelvic area, and improve sexual function. Regularly practicing these exercises under the guidance of a healthcare provider or physical therapist can be a key part of long-term pain management and pelvic health.

TENS Therapy

TENS therapy uses gentle electrical currents through electrodes on your skin to modulate pain signals sent by nerves, reducing your perception of pain. It's found to be particularly effective in managing pelvic pain and cramping during menstruation or acute symptom periods. Portable TENS units allow you to use this therapy at home, providing a convenient, inexpensive, and drug-free option for pain management.

Psychological Support and Counseling

Living with endometriosis can also impact your mental and emotional health due to chronic pain, fertility issues, and effects on daily life and relationships. Psychological support and counseling play a crucial role in tackling stress, anxiety, and depression, and in developing effective coping strategies. Techniques like cognitive behavioral therapy (CBT), mindfulness-based stress reduction (MBSR), and relaxation methods can help manage symptoms and build resilience. Support groups and online communities also offer peer support, validation, and motivation, helping to foster a sense of connection and empowerment within the endometriosis community.

In summary, endometriosis presents complex challenges, yet a range of treatment options exists to manage and relieve symptoms and enhance well-being, so don’t lose hope!

References

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2. Tasuku Harada, Mikio Momoeda, Yuji Taketani, Hiroshi Hoshiai, Naoki Terakawa. Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis: a placebo-controlled, double-blind, randomized trial. Fertility and Sterility, 90(5),2008, 1583-1588,
3. Xholli A, Filip G, Previtera F, Cagnacci A. Modification of endometrioma size during hormone therapy containing dienogest. Gynecol Endocrinol. 2020 Jun;36(6):545-549.
4. Kizilkaya Y, Ibanoglu MC, Kıykac Altinbas S, Engin-Ustun Y. A prospective study examining the effect of dienogest treatment on endometrioma size and symptoms. Gynecol Endocrinol. 2022 May;38(5):403-406.
5. Vignali M, Belloni GM, Pietropaolo G, Barbasetti Di Prun A, Barbera V, Angioni S, Pino I. Effect of Dienogest therapy on the size of the endometrioma. Gynecol Endocrinol. 2020 Aug;36(8):723-727.
6. Barra F, Scala C, Leone Roberti Maggiore U, Ferrero S. Long-Term Administration of Dienogest for the Treatment of Pain and Intestinal Symptoms in Patients with Rectosigmoid Endometriosis. J Clin Med. 2020 Jan 6;9(1):154
7. Bofill Rodriguez M, Lethaby A, Farquhar C. Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019 Sep 19;9(9):CD000400.
8. Porpora MG. A promise in the treatment of endometriosis: an observational cohort study on ovarian endometrioma reduction by N-acetylcysteine. Evid Based Complement Alternat Med. 2013;2013:240702.
9. Cobellis L, Castaldi MA, Giordano V, Trabucco E, De Franciscis P, Torella M, Colacurci N. Effectiveness of the association micronized N-Palmitoylethanolamine (PEA)-transpolydatin in the treatment of chronic pelvic pain related to endometriosis after laparoscopic assessment: a pilot study. Eur J Obstet Gynecol Reprod Biol. 2011 Sep;158(1):82-6.
10. Nodler JL, DiVasta AD, Vitonis AF, Karevicius S, Malsch M, Sarda V, Fadayomi A, Harris HR, Missmer SA. Supplementation with vitamin D or ω-3 fatty acids in adolescent girls and young women with endometriosis (SAGE): a double-blind, randomized, placebo-controlled trial. Am J Clin Nutr. 2020 Jul 1;112(1):229-236.
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12. Bougie O, McClintock C, Pudwell J, Brogly SB, Velez MP. Long-term follow-up of endometriosis surgery in Ontario: a population-based cohort study. Am J Obstet Gynecol. 2021 Sep;225(3):270.e1-270.e19

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