Treatments for Endometriosis

 

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

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.

 

At present, there is no definitive cure for endometriosis. There is no simple way to remove the condition in the way that we can completely remove the appendix to treat appendicitis or take antibiotics to kill the bacteria causing pneumonia.

Treatments for endometriosis have the potential to reduce the impacts of the condition and alleviate the symptoms associated with it. There is, however, the possibility that endometriosis and its associated symptoms may return over time.

When to treat endometriosis

Endometriosis is a benign disease and does not always require treatment.

The most common reason to treat endometriosis is to alleviate its symptoms, which, in some cases, can be quite severe and debilitating. Typically, treatment for endometriosis is considered when pain and/or infertility are present and distressing to the patient.

Treatment Options

Endometriosis can be treated medically (with drugs), surgically, or with a combination of both. Adjunct therapies such as physiotherapy, physical exercise, healthy diet, weight loss, and mindfulness have also shown some positive effects in symptom reduction.

Treatment for Pain Symptoms

Conservative Management

The first option for the treatment of benign, non-life-threatening conditions is to do nothing. This option must be considered carefully, weighing all of the risks and benefits. In cases with mild or no pain, or in individuals who are approaching menopause, this could be the best option.

 
 
 

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

Several different pain killers have the potential to reduce endometriosis-related pain. When the pain is not very severe and only for a few days a month, many women will experience good relief of symptoms with over-the-counter drugs. Typical pain relief medications 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 effective

  • 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

The growth of endometriotic cells is stimulated by the hormones produced by the ovaries during the menstrual cycle.

Medications containing hormones or other substances that affect the production and action of the body’s hormones have the potential to change the progression of endometriotic lesions and reduce pain symptoms. Several studies have confirmed the improvement of pain with hormone treatments, with no particular option appearing to be significantly better than the other.

 

Progesterone-like Medications

Available in different formulations including:

 

  • Norethindrone acetate

  • Levonorgestrel

  • Dienogest

 

  • Medroxyprogesterone

 

  • Levonorgestrel

 

  • Etonogestrel

 
 

Advantages

  • Reduced pain

  • Lighter or no periods

  • Stops endometriosis growth in most cases

  • Some are contraceptive

 

Disadvantages

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

  • Endometriosis symptoms may recur when treatment is stopped

  • They don’t always work for everyone

  • Doesn’t improve fertility

 

 Combined Estrogen/Progestagen

 
 

Most of the pills commonly used for contraception can be used to reduce menstrual flow heaviness and related menstrual pain. They have been shown to also reduce endometriosis pain and slow the progression of the disease.

There are several estrogen and progestogen-containing products on the market, each containing which vary from brand to brand. Different pills are tolerated better or worse by different people. Sometimes, it is necessary to try two or three different ones in order to find the one that works best.

 

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

  • Reduced pain

  • Can be taken to reduce or stop periods

  • Does not require taking one tablet every day

 

Disadvantages

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

  • Doesn’t always work for everyone

 

Gonadotropin-Releasing Hormone Analogues (GnRH)

Another way of treating endometriosis-related pain is to completely stop ovarian activity. A group of drugs called GnRH analogues stop ovulation and the production of ovarian hormones altogether. The 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 such as Norethindrone acetate. Long-term use can cause loss of bone density and hormone replacement therapy 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

  • Very effective in reducing pain

  • Stops periods

  • Stops endometriosis growths in most cases

Disadvantages

  • Side-effects include hot flashes and sweats

  • Need to add hormone replacements to prevent bone thinning if used for more than 6-months

  • Symptoms may recur when treatment is stopped

  • Expensive

  • Does not work for everyone

 

 Surgery

 

Laparoscopic Surgery

Surgery for endometriosis is usually done via laparoscopy (keyhole surgery), whereas a laparotomy (an open, larger incision) is rarely ever necessary these days.

 
 

Laparoscopy has two main objectives:

  1. Definitive Diagnosis

    Sometimes endometriosis can be diagnosed by ultrasound or MRI, but even then, it is not a definitive diagnosis. In most cases, the clinical diagnosis of the disease needs to be confirmed by a laparoscopy, where the surgeon removes the lesions and sends them for examination under the microscope (histopathology).

  2. Treatment of Endometriosis

    The objective of surgical treatment of endometriosis is to remove the areas that contain endometrial tissue, also known as endometriotic lesions or endometriotic patches.

    The areas containing endometriotic lesions are excised using special instruments. If the ovaries contain endometriotic cysts, these are also excised.

    Laparoscopic surgery for endometriosis is deemed ‘fertility sparing’, as the aim is to preserve the uterus and the ovaries as well as to normalize pelvic anatomy so that the individual can potentially become pregnant in the future if desired.

Sometimes, endometriosis affects nearby organs such as the wall of the bowel. When this is causing significant bowel symptoms, such as severe pain with bowel movements, consideration must be given to the removal of the affected segment of bowel. This is an uncommon situation and requires a specialized bowel surgeon working together with the gynecologist.

Ongoing hormonal treatment, as described previously, is often used after surgery to enhance the reduction of symptoms, and reduce the risk of endometriosis recurrence.

 
 

Advantages

  • Definitive diagnosis

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

Disadvantages

  • Not all endometriosis can be treated this way

  • Risks associated with surgery

  • A small number of women will not experience a reduction in pain or will have a recurrence of symptoms after 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 individuals 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. This approach is particularly significant in patients who have adenomyosis, a different form of endometriosis where the endometrium invades the muscular layer of the uterine walls.

Consideration of an individual’s desire for fertility is paramount, as pregnancy is not possible after such a procedure. A hysterectomy cannot be considered in individuals who still want to preserve their fertility.

 
 

Advantages

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

  • Removes the source of most/recurrent endometriosis

  • No need to use further medications

  • No more menstrual bleeding

Disadvantages

  • Risk of Surgery

  • End of fertility

  • The potential of psychological impact from losing an organ important to some individuals

  • Like other treatments, there is 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 women experience improvement of their symptoms with these but there is no scientific evidence yet that says that Chinese medicines can reduce symptoms or improve fertility.

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 Infertility Symptoms

 

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

None of the medications described above has been shown to improve fertility and many of them are contraceptives and therefore 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 infertility in the couple, individuals who have endometriosis and are not able to conceive should consider the following options:

 
 

  1. Surgery to Treat Endometriosis

    Some studies have shown that removing the endometriosis improves the odds of conceiving. This is particularly true for individuals with mild forms of the condition where the fallopian tubes are working and there is no major invasion of 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 of Surgery + ART

    Lastly, some women may require 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 fertility, etc. The decision to operate is based on individual circumstances, the presence or absence of pain symptoms, and the availability of other treatment options.