Treatments for Endometriosis

 

What is Endometriosis? | Causes of Endometriosis | Symptoms | How is it Diagnosed? | Treatments for Endometriosis | Endometriosis FAQ

Currently, there is no cure for endometriosis.
Treatments can reduce the symptoms, but there is a possibility that endometriosis and its associated
symptoms may return over time.

 

When to treat endometriosis

Endometriosis is not cancerous (benign) and does not always require treatment.

The most common reason to treat endometriosis is to reduce the symptoms, which can be quite severe and may impact your quality of life. Treatment is typically considered when the goal is to reduce pain symptoms or getting pregnant is desired by the patient.

 

Treatment Options

Endometriosis can be treated conservatively (no medical treatment), with pain-relief medications, with hormonal medications, with surgery, or a combination of treatments. Additional therapies such as physiotherapy, physical exercise, healthy diet, weight loss, and mindfulness have also been found to help manage symptoms.

 

Treatment for Pain Symptoms

Conservative Management

Depending on each patient’s symptoms, the best option may be to do nothing. This option must be considered carefully by both you and your physician, weighing all of the risks and benefits. This may be the course of treatment for cases with mild or no pain, or in individuals who are approaching menopause. The addition of alternative therapies (e.g. physiotherapy, yoga, etc.) and lifestyle changes (e.g. physical exercise, diet changes, mindfulness, etc.) may be considered as well.

 
 
 
 

Advantages

  • No side effects of drugs

  • No risks of surgery

  • Symptoms may improve on their own

Disadvantages

  • Most symptoms continue

  • Some symptoms may get worse

  • The disease is not actually being treated

 

Pain Relief Medication

There are several different medications available to relieve the pain associated with endometriosis. Use of pain relief medications is often considered with the pain is not very severe and/or is only present for a few days a month; patients who present with these symptoms generally experience good pain relief from over-the-counter drugs.

Typical pain relief medications in Canada include:

Acetaminophen (e.g. Tylenol®, etc.)

 
 
 

Non-steroidal anti-inflammatory drugs (NSAIDs): Ibuprofen (e.g. Advil™, ), Diclofenac (e.g. Voltaren™), Naproxen, Mefenamic Acid.

 

Advantages

  • Easy to obtain

  • Side effects uncommon

Disadvantages

  • May not be as effective in cases with severe pain

  • Stomach ulcer risk with prolonged use of non-steroidal anti-inflammatory medications

 

Sometimes prescription pain medication may be necessary, and you should seek advice from your doctor.

 Hormonal treatments

Endometriosis growths change in size with the hormones produced over the course of a period or menstrual cycle. As such, medications using hormones or other substances to change your bodies’ hormones may change the growth cycles of the endometriosis and reduce pain symptoms.

There is no particular hormonal medication that is better than the other in the treatment of endometriosis according to current research.

 

Progesterone-like Medications

Available in different formulations including:

 

  • Norethindrone acetate

  • Levonorgestrel

  • Dienogest

 

  • Medroxyprogesterone

 
Intra-Uterine Device

  • Levonorgestrel

 
Under Skin Impant

  • Etonogestrel

 
 

Advantages

  • Reduced pain

  • Lighter or no periods

  • Stops endometriosis growth
    in most cases

  • Some are contraceptive
    (able to prevent pregnancy)

Disadvantages

  • Side effects may include weight gain, moodiness, acne, cramps, breast tenderness, irregular bleeding

  • Endometriosis symptoms may come back when treatment is stopped

  • They do not always work for everyone

  • Does not help patients get pregnant if this is a patient goal

 

 Combined Estrogen/Progestagen

 
Combined Oral Contraceptive Pill
 

Most of the pills commonly used for contraception (preventing pregnancy) can be used to reduce blood flow during your period (menstrual flow) and related period pain. They have been shown to also reduce endometriosis pain and slow the progression of the disease.

There are several estrogen and progestogen combination products on the Canadian market. Different pills work differently for different people, and it is sometimes necessary to try two or three different ones to find the one that works best for you.

 
Vaginal Contraceptive Ring
 

The ring has the same hormones and works similarly to the pill. Instead of taking one pill every day, the ring is inserted in the vagina, from where the medication is absorbed into the bloodstream. The ring is replaced once every four weeks.

 
 
 
 

 Advantages

  • Contraceptive (prevents pregnancy)

  • Reduced pain

  • Can be taken to reduce or stop periods

  • Vaginal ring does not require taking one tablet every day

Disadvantages

  • Side effects may include nausea, weight gain, mood changes

  • Does not work for everyone

  • Oral contraceptives must be taken every day

 

 Gonadotropin Releasing Hormone (GnRH) Analogues

Another way of treating endometriosis-related pain is to completely stop the ovarian activity. A group of drugs called GnRH analogues stop ovulation and the production of some hormones completely. This type of medication induces a temporary and fully reversible state of artificial menopause.

The side effects can be quite troubling but can be treated with small doses of hormone replacement therapy (HRT) such as Norethindrone acetate. Long-term use can cause loss of bone density and HRT is required if the medication is used for more than 6 months.

The main commercially available compounds come in either a daily nasal spray (Nafarelin which is self-administered by the patient) or monthly injection (Goserelin or Leuprolide acetate which is usually administered by a health professional).

Recently, oral GnRH antagonists have also become available. These oral medications only partially suppress ovarian activity depending on the doses provided. Currently, the only Canadian-approved GnRH oral antagonist is Elagolix.

 
 

Advantages

  • Effective in reducing pain

  • Stops periods

  • Stops endometriosis growth in most cases

 Disadvantages

  • Side effects include menopause symptoms, such as hot flashes and sweats

  • Need to add hormone replacement therapy to prevent bone loss if used for more than six months

  • Symptoms may come back when treatment is stopped

  • Expensive

  • Does not work for everyone

 

 Surgery

 

Laparoscopic Surgery

Surgery for endometriosis is usually done via laparoscopy (keyhole surgery). This type of surgery can be both a diagnostic procedure and a part of the treatment, as the endometriotic growths can be viewed and removed at the same time. Your surgeon may discuss the option of removing one or both of the fallopian tubes or ovaries if they are greatly affected by endometriosis. If you wish to get pregnant in the future, the surgeon will do their best to ensure they preserve your fertility as much as possible.

 

Surgery goals:

 
 

  1. Definitive diagnosis.

    Sometimes endometriosis can be diagnosed by ultrasound or MRI, but even then, it is not a conclusive diagnosis. In most cases, the clinical diagnosis of endometriosis needs to be confirmed by a laparoscopy, where the surgeon removes the lesions and sends them for testing to find out what type of tissue is in the growth.

  2. Treatment of the endometriosis

    During surgical treatment of endometriosis, the growths and/or cysts can be removed. These growths are removed using specialized tools that can help to keep the uterus and ovaries functional for pregnancy if the patient would like to pursue this path.

 

Sometimes, endometriosis affects nearby organs such as the wall of the bowel. When this is causing symptoms, such as severe pain while pooping, the surgeon may discuss with the patient the option of removing a segment of the bowel that is affected by endometriosis. This is an uncommon situation and requires a specialized bowel surgeon working together with the gynecologist.

Surgical treatment is often combined with hormonal medications to help further reduce symptoms and the risk of the endometriosis returning.

 
 

Advantages

  • Ability to make a definitive diagnosis

  • Long-term reduction of symptoms in up to 70% of women

Disadvantages

  • Not all endometriosis can be treated this way

  • Risks associated with surgery

  • Small number of women will not experience a reduction in pain or their symptoms will return in a few months or years

 
 

Hysterectomy and Removal of Endometriosis

Hysterectomy is NOT A CURE for endometriosis, but it can address pain or symptoms related to menstruation.

In a small group of patients with severe symptoms that are not relieved by medical or surgical treatment, more extensive surgery such as a hysterectomy may be considered. This is a procedure in which the entire uterus is removed during surgery, typically laparoscopically (performed minimally rather than open surgery). This approach is often considered for patients who have another condition called adenomyosis, a different form of endometriosis where the endometrium (inner layer of the uterus) invades the muscular layer of the uterus.

Consideration of a patient’s desire for future pregnancy is very important in treatment decisions. After a hysterectomy, pregnancy is not possible.

 
 
 

Advantages

  • Long-term symptom relief in over
    90% of women

  • Removes the source of most
    new/recurrent endometriosis

  • No need to use further medications

  • No more periods

Disadvantages

  • Risks of surgery

  • No chance of future pregnancy

  • Potential psychological impact from losing an organ that is considered important to some patients

  • No guarantee that the pain will be completely fixed

 

 Alternative and Complimentary Therapies

There are many other treatments available that can either complement medical treatment or are an alternative to medical treatment. The most popular is traditional Chinese medicine and herbal preparations. Some patients experience improvement of their symptoms with these but there is no scientific evidence yet that says that Chinese medicines can reduce symptoms or improve chances of pregnancy.

If you use complementary treatments, it is wise to discuss their use with your doctor, as they may interfere with other prescribed medications.

 Treatment for Fertility Symptoms

 

None of the medications described above have been shown to improve chances of future pregnancy and many of them are contraceptives (prevent pregnancy.)

Some individuals who have endometriosis will get pregnant on their own without any treatment.

After undergoing a full investigation for other reasons for difficulty in getting pregnant, individuals who have endometriosis and are not able to get pregnant should consider the following options:

 
 

  1. Surgery to Treat Endometriosis

    Some studies have shown that removing the endometriosis improves the odds of getting pregnant. This is particularly true for individuals with mild forms of the condition where the fallopian tubes (of the uterus) are working and there are invasive endometriosis growths on the other pelvic organs.

  2. Assisted Reproductive Treatment (ART)

    In other cases, ART options can be attempted without surgery, the most common one is in vitro fertilization (IVF).

  3. Combination (Surgery + ART)

    Lastly, some women may require both the above options: surgery to remove the endometriosis followed by IVF.

    There is no one option that suits everyone. Endometriosis presents in many different ways with varying degrees of severity. Every patient is unique, and their treatment will depend on age, the severity of disease, the severity of symptoms, desire for future pregnancy, etc.

    The decision to operate is based on individual circumstances, the presence or absence of pain symptoms, and the availability of other treatment options.