Endometriosis Treatment Options
Endometriosis is a condition in which cells similar to those in the endometrium, the layer of tissue that normally covers the inside of the uterus, grow outside it. The main symptoms are pelvic pain and infertility. Many of those affected have chronic pelvic pain, which leads them to seek treatment.
Endometriosis can be treated or managed in multiple ways depending on each patient’s unique medical condition. Management or treatment options for endometriosis include medication, hormone therapy, surgical management or alternative treatments (like physical therapy and supplements).
To effectively treat endometriosis, surgical management is usually recommended. A laparoscopic examination with biopsy of suspected endo lesions is the only way to accurately confirm the diagnosis. Delaying treatment allows the disease to spread further and pain to progress, so surgical removal (endometriosis excision) is highly recommended. Other methods such as medication and hormone therapy are typically recommended as complementary follow-up methods to prevent or delay recurrence of the disease and manage pain after surgery.
The goals of treatment are:
- Reducing and relieving pain
- Slowing the growth of endometriosis
- Maintaining or regaining fertility
- Preventing the condition from returning
Treatment plans may be affected by:
- Medical history
- Severity of symptoms
- Severity of disease growth
- Tolerance for medications or procedures
- Projection for the disease’s advancement
- Desire to get pregnant
Surgery is the most important first step in the diagnosis and proper treatment of endometriosis. Endometriosis is a small volume disease that usually cannot be diagnosed by pelvic ultrasound, CT scan or MRI. Endometriosis lesions may be too small to be detected by these imaging studies. Because of this, we recommend that most patients with symptoms like pain or infertility — in all reproductive ages — have a laparoscopy to both diagnose and remove the disease at the time of surgery.
OBGYNs often bypass surgery and make a diagnosis based on clinical assessment alone, without definitive confirmation of the diagnosis via laparoscopy. This allows the disease to spread, causing increasing inflammation, pain and risk of infertility. In contrast, surgical removal confirms the diagnosis (or finds a coexisting diagnosis), controls pain and inhibits the progression of the disease.
Conservative surgery preserves the uterus, fallopian tubes and ovaries and removes only the endometriosis. Conservative surgery with endometriosis excision will decrease pain, but it does not cure endometriosis. Following conservative surgery with medical management can help extend the length of pain control.
Endometriosis excision is a minimally invasive surgical technique in which surgeons remove endometriotic lesions. These lesions can develop on tissue within the pelvic cavity. A highly skilled endometriosis specialist will meticulously remove each endometriosis lesion along with its root, making regrowth less likely. Thorough removal of all visible endometriosis, especially in a patient’s initial surgery for the disease, has been shown to have maximum therapeutic benefit.1
Endometriosis Fulguration (Burning)
Burning (also known as ablation, fulguration or cauterization) of endometriosis lesions is less effective than excision, mainly due to incomplete removal of the disease2. These surgical procedures remove only the visible portion of endometriosis lesions, often leaving behind the root. Any endometriosis that is not removed is likely to contribute to further growth of the disease, ongoing pain and, eventually, the need for reoperation. Burning of endometriosis implants should not be performed when the disease involves the bowel, bladder, ureters or pelvic sidewall and vessels because it could cause significant injury to those structures.
Resection of Ovarian Endometriomas
Endometriomas should be completely removed, not just drained, and the ovary preserved. If an ovarian endometrioma is not completely removed, it can regrow.2,3 In most cases, it is not necessary to remove the ovary while removing the endometrioma. For women of childbearing age, removing one ovary will decrease the chance of becoming pregnant in the future.
Longer-Term Surgical Solutions
More effective, longer-term surgical options include hysterectomy and presacral neurectomy. These solutions provide longer-term relief compared to more conservative management options.
Hysterectomy, with or without removal of the ovaries (bilateral salpingopherectomy), can be performed for women who do not desire fertility. Hysterectomy is also the recommended option when conservative surgery has not been sufficient to manage pain or other severe symptoms.
Of all of the methods to treat endometriosis, a hysterectomy with removal of both ovaries results in the most effective long-term pain control. If the ovaries are not removed, the chance that symptoms will return is six to eight times higher than if they are removed.4,5 However, for many younger women who have completed childbearing but do not want to begin menopause, a hysterectomy — without removal of the ovaries — does provide significant pain relief.
For women with extreme pain that is concentrated in the middle of the pelvis, cutting the nerves that sense pain in that area can improve symptoms. However, for women with generalized pain, or pain in areas other than the middle of the pelvis, this procedure has not been shown to be more effective than endometriosis excision. The procedure also carries some high risks, including postoperative chronic constipation and urinary dysfunction.6
CIGC surgeons recommend endometriosis excision over other surgical options because there is nearly universal acceptance among endometriosis specialists that excision results in more complete removal of the disease.1 More thorough removal means less chance of symptom recurrence and the need for reoperation.
After the diagnosis and surgical excision of endometriosis, medical suppression is often used to manage any residual symptoms and decrease the likelihood of recurrence. It is important to note that suppression of endometriosis with medical therapies will likely be more successful and last for a longer period of time after complete resection of all disease.
Pain from endometriosis is most commonly managed with NSAIDs such as ibuprofen, Motrin and Advil. Narcotic medications (such as Vicodin, Percocet, Tylenol-Codeine #3) can be used for more severe pain but are associated with side effects and are not recommended for long-term care. Always consult with your primary care physician or OBGYN when considering narcotics for pain management.
Hormonal medication is used to inhibit the growth of the endometriotic cells by reducing the production of estrogen. Because many women experience their worst symptoms during their periods, hormonal management that stops periods from occurring (by stopping ovulation) can be helpful and are usually well-tolerated. Suppression of ovulation through medical therapies such as birth control, IUDs, Depo-Provera, Lupron and Orilissa can stunt the growth of endometriosis.7
Unfortunately, the effects of hormonal medication are temporary. Symptoms of endometriosis usually return once the medication is stopped.
Other holistic treatments for endometriosis include pain management, pelvic floor physical therapy, acupuncture, physical training, nutritional counseling and psychotherapy. These holistic treatments can be used to manage symptoms in mild cases. These treatments typically work as a complement to surgery and are not recommended as a long-term solution. Consult with a physician before trying these alternatives on your own.
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- Johnson NP, Hummelshoj L; World Endometriosis Society Montpellier Consortium. Consensus on current management of endometriosis. Hum Reprod. 2013;28(6):1552-1568. doi:10.1093/humrep/det050
- Chan L, So W, Lao T. Rapid recurrence of endometrioma after transvaginal ultrasound-guided aspiration. Eur J Obstet Gynecol Reprod Biol. 2003;109(2):196-8
- Küçükbaş M, Kurek Eken M, İlhan G, Şenol T, Herkiloğlu D, Kapudere B. Which factors are associated with the recurrence of endometrioma after cystectomy?. J Obstet Gynaecol. 2018;38(3):372-376. doi:10.1080/01443615.2017.1355897
- Rizk B, Fischer AS, Lotfy HA, et al. Recurrence of endometriosis after hysterectomy. Facts Views Vis Obgyn. 2014;6(4):219-227.
- Vercellini P, Barbara G, Abbiati A, Somigliana E, Viganò P, Fedele L. Repetitive surgery for recurrent symptomatic endometriosis: what to do?. Eur J Obstet Gynecol Reprod Biol. 2009;146(1):15-21. doi:10.1016/j.ejogrb.2009.05.007
- Nezhat CH, Seidman DS, Nezhat F, Nezhat C. Are the long-term adverse effects of laparoscopic presacral neurectomy for the management of central pain associated with endometriosis acceptable?. Prim Care Update Ob Gyns. 1998;5(4):197. doi:10.1016/s1068-607x(98)00129-2
- Taylor H, et al. Treatment of endometriosis-associated pain with elagolix, an oral GnRH antagonist. NEJM. 2017;377:28-40