Endometriosis Treatment

The most common types of pain relievers are nonsteroidal anti-inflammatory drugs, also called NSAIDS (pronounced ENN-sedds), and opioids (pronounced OH-pee-oyds), strong pain drugs that interact directly with the nervous system.

Evidence on the effectiveness of these medications for relieving endometriosis-associated pain is limited. Understanding which drugs relieve pain associated with endometriosis could also shed light on how endometriosis causes pain.^1,2

Hormone Treatments

Because hormones cause endometriosis patches to go through a cycle similar to the menstrual cycle, hormones also can be effective in treating the symptoms of endometriosis. Additionally, our perception of pain may be altered by different hormones.

Hormone therapy is used to treat endometriosis-associated pain. Hormones come in the form of a pill, a shot or injection, or a nasal spray.

Hormone treatments stop the ovaries from producing hormones, including estrogen, and usually prevent ovulation. This may help slow the growth and local activity of both the endometrium and the endometrial lesions. Treatment also prevents the growth of new areas and scars (adhesions), but it will not make existing adhesions go away.

Health care providers may suggest one of the hormone treatments described below to treat pain from endometriosis:^3,2,4

• Oral contraceptives, or birth control pills. These help make your period lighter, more regular, and shorter. Women prescribed contraceptives also report relief from pain.⁵
  • In general, the therapy contains two hormones-estrogen and progestin, a progesterone-like hormone. Women who can’t take estrogen because of cardiovascular disease or a high risk of blood clots can use progestin-only pills to reduce menstrual flow.
  • Typically, a woman takes the pill for 21 days and then takes sugar pills for 7 days to mimic the natural menstrual cycle. Some women take birth control pills continuously, without using the sugar pills that signal the body to go through menstruation. Taken without the sugar pills, birth control pills may stop the menstrual period altogether, which can reduce or eliminate the pain. There are also birth control pills available that provide only a couple days of sugar pills every 3 months; these also help reduce or eliminate pain.
  • Pain relief usually lasts only while taking the pills, while the endometriosis is suppressed. When treatment stops, the symptoms of endometriosis may return (along with the ability to get pregnant). Many women continue treatment indefinitely. Occasionally, some women have no pain for several years after stopping treatment.
  • There are some mild side effects from these hormones, such as weight gain, bloating, and bleeding between periods (especially when women first start to take the pills continuously).
• Progesterone and progestin, taken as a pill, by injection, or through an intrauterine device (IUD), improve symptoms by reducing a woman’s period or stopping it completely. This also prevents pregnancy.
  • As a pill taken daily, these hormones reduce menstrual flow without causing the uterus lining to grow. As soon as a woman stops taking the progestin pill, symptoms may return and pregnancy is possible.
  • An IUD containing progestin may be effective in reducing endometriosis-associated pain. It reduces the size of lesions and reduces menstrual flow (one third of women no longer get their period after a year of use).⁶
  • As an injection taken every 3 months, these hormones usually stop menstrual flow. However, one-third of women bleed several times in the first year of injection use. During these times of bleeding, pain may occur. Additionally, it may take a few months for a period to return after stopping the injections. When menstruation starts again, the ability to get pregnant returns.
  • Women taking these hormones may gain weight, feel depressed, or have irregular vaginal bleeding.
• Gonadotropin-releasing hormone (GnRH) agonists (pronounced AG-uh-nists) stop the production of certain hormones to prevent ovulation, menstruation, and the growth of endometriosis. This treatment sends the body into a “menopausal” state.
  • GnRH agonists come in a nose spray taken daily, as an injection given once a month, or as an injection given every 3 months.
  • Most health care providers recommend staying on GnRH agonists for only about 6 months at a time, with several months between treatments if they are repeated. The risk for heart complications and bone loss can rise when taking them longer.² After stopping the GnRH agonist, the body comes out of the menopausal state, menstruation begins, and pregnancy is possible.⁷
  • As with all hormonal treatments, endometriosis symptoms return after women stop taking GnRH agonists.
  • These medications also have side effects, including hot flashes, tiredness, problems sleeping, headache, depression, joint and muscle stiffness, bone loss, and vaginal dryness.
• Danazol (pronounced DAY-nuh-zawl) treatment stops the release of hormones that are involved in the menstrual cycle. While taking this drug, women will have a period only now and then or sometimes not at all.
  • Common side effects include oily skin, pimples or acne, weight gain, muscle cramps, tiredness, smaller breasts, and sore breasts. Headaches, dizziness, weakness, hot flashes, or a deepening of the voice may also occur while on this treatment. Danazol’s side effects are more severe than those from other hormone treatment options.²
  • Danazol can harm a developing fetus. Therefore, it is important to prevent pregnancy while on this medication. Hormonal birth control methods are not recommended while on danazol. Instead, health care providers recommend using barrier methods of birth control, such as condoms or a diaphragm.

Researchers are exploring the use of other hormones for treating endometriosis and the pain related to it. One example is gestrinone (pronounced GES-trih-nohn), which has been used in Europe but is not available in the United States. Drugs that lower the amount of estrogen in the body, called aromatase (pronounced uh-ROH-muh-tase) inhibitors, are also being studied. Some research shows that they can be effective in reducing endometriosis pain, but they are still considered experimental in the United States. They are not approved by the Food and Drug Administration for treatment of endometriosis.⁸

Surgical Treatments

Research shows that some surgical treatments can provide significant, although short-term, pain relief from endometriosis,² so health care providers may recommend surgery to treat severe pain from endometriosis. During the operation, the surgeon can locate any areas of endometriosis and examine the size and degree of growth; he or she also may remove the endometriosis patches at that time.

It is important to understand what is planned during surgery as some procedures cannot be reversed and others can affect a woman’s fertility. Therefore, a woman should have a detailed discussion with a health care provider about all available options before making final decisions about treatment.

Health care providers may suggest one of the following surgical treatments for pain from endometriosis.^1,2,3

• Laparoscopy. The surgeon uses an instrument to inflate the abdomen slightly with a harmless gas and then inserts a small viewing instrument with a light, called a laparoscope, into the abdomen through a small cut to see the growths.
  • To remove the endometriosis, the surgeon makes at least two more small cuts in the abdomen and inserts lasers or other surgical instruments to:
    • Remove the lesions, which is a process called excising (pronounced eks-SIZE-ing).
    • Destroy the lesions with intense heat and seal the blood vessels without stitches, a process called cauterizing (pronounced KAW-tur-ize-ing) or vaporizing.
  • Some surgeons also will remove scar tissue at this time because it may be contributing to endometriosis-associated pain.
  • The goal is to treat the endometriosis without harming the healthy tissue around it.
  • Although most women have relief from pain with surgery in the short term, pain often returns.² The excision of deep lesions seems to be associated with long-term pain relief.
  • Some evidence shows that surgical treatment for endometriosis-related pain is actually more effective in women who have moderate endometriosis rather than minimal endometriosis. The reason is that women with minimal endometriosis may have changes in their pain perception that persist after the lesions are removed.^1,6
• Laparotomy. In this major abdominal surgery procedure, the surgeon may remove the endometriosis patches. Sometimes, the endometriosis lesions are too small to see in a laparotomy.
  • During this procedure, the surgeon may also remove the uterus. Removing the uterus is called hysterectomy (pronounced his-tuh-REK-tuh-mee).
  • If the ovaries have endometriosis on them or if damage is severe, the surgeon may remove the ovaries and fallopian tubes along with the uterus. This process is called total hysterectomy and bilateral (meaning “on both sides”) salpingo-oophorectomy (pronounced sal-PING-go ooh-for-EK-toh-mee).
  • When possible, health care providers will try to leave the ovaries in place because of the important role ovaries play in overall health.
  • Health care providers recommend major surgery as a last resort for endometriosis treatment.
  • Having a hysterectomy or salpingo-oophorectomy does not guarantee that the lesions will not return or that the pain will go away. There’s still a slight chance that endometriosis symptoms and lesions may come back in some women even if they have a total hysterectomy with bilateral salpingo-oophorectomy.²
• Surgery to sever pelvic nerves. If the pain is located in the center of the abdomen, health care providers may recommend cutting nerves in the pelvis to lessen the pain. This can be done during either laparoscopy or laparotomy.²
  • Two procedures are used to sever different nerves in the pelvis.
    • Presacral neurectomy (pronounced pree-SEY-kruhl [or pree-SAK-ruhl]) nyoo-REK-tuh-mee). This procedure severs the nerves connected to the uterus. Research shows that this procedure can be useful in relieving pain along the center of the abdomen.^6,8
    • Laparoscopic uterine nerve ablation (pronounced  a-BLEY-shuhn) (LUNA) This procedure involves severing nerves in the ligaments that secure the uterus. However, studies have shown that LUNA did not relieve pain any better than laparoscopy alone. For this reason, it is generally not recommended for treatment of endometriosis-associated pain.^2,6,8
  • The American College of Obstetricians and Gynecologists (ACOG) reports several clinical trials that showed these procedures to be ineffective at relieving pain from endometriosis. These procedures are not currently included in the ACOG recommendations for management of endometriosis.²

In some cases, hormone therapy is used before or after surgery to reduce pain and/or continue treatment. Current evidence supports the use of an intrauterine device (IUD) containing progestin after surgery to reduce pain.⁶