What is the treatment for endometriosis?

For the purpose of this article 'girls, females, or women' are those individuals assigned as female at birth. It is not intended to exclude or dismiss individuals who do not identify as female.

Endometriosis affects women differently. The right treatment depends on each woman's preferences, the symptoms they are experiencing, and on how severe the endometriosis is, including which organs it's affecting.

The main treatments for endometriosis include:

• Pain relief medication.

• Hormone treatment - such as contraceptives, including combined hormonal contraception (patches, pills, and rings), the progesterone-only pill (minipill), the contraceptive injection, the contraceptive implant, and the intrauterine system (IUS) including the brands Mirena, Jaydess, and Kyleena.

• Other types of hormone therapy - such as gonadotrophin relating hormone (GnRH) analogues. These, essentially, produce a temporary and reversible menopause.

• Surgery - there are many different types of surgery which are looked at further on.

• Alternative ways of managing pain and other endometriosis symptoms - such as diet, exercise, acupuncture, and pain management psychology. There is not much evidence yet that clearly shows which, if any, of these can improve symptoms of endometriosis, but some women seem to find them helpful.

• Fertility treatments - if there are difficulties in getting pregnant.

If you think you may have endometriosis, find out what to do here. This will tell you if you need to see a doctor and how it is treated.

In this series of articles centred around endometriosis you can read about endometriosis symptoms, endometriosis treatment, and endometriosis causes - all written by one of our expert GPs.

The rest of this feature will take an in-depth look at the treatments of endometriosis as, at Patient, we know our readers sometimes want to have a deep dive into certain topics.

Endometriosis treatment

Treatment options include:

Pain medication

Endometriosis is a painful condition. Some women experience pain around the time of their period, others have severe, continuous pain.

Pain relief medication that can help with these symptom include:

• Non-steroidal anti-inflammatory drugs (NSAIDs) - such as ibuprofen, naproxen, and mefenamic acid. These are thought to reduce inflammation and lower the production of prostaglandins, both of which are thought to be key factors in endometriosis. They can have some side-effects, such as stomach irritation and ulcers in the stomach that can cause bleeding - particularly with long-term use.

• Paracetamol - useful for mild pain. If taken at the correct dose it has very few side-effects and may also boost the effect of other types of pain medication if taken alongside them - such as NSAIDs.

• Opiate medications - such as codeine or dihydrocodeine can be used for moderate or severe pain, and should be used sparingly. They can have side-effects, such as constipation - which can make endometriosis worse - nausea, vomiting, and a risk of dependence if used long-term.

• Other types of pain medication - for long lasting (chronic) pain, particularly if due to nerve problems (neuropathic pain). These tend to work on the brain and central nervous system, affecting how the brain processes pain signals. These include antidepressants - although these are being used for their effect on nerve signalling, not to treat depression - such as amitriptyline or duloxetine, and other medicines such as gabapentin or pregabalin. A doctor may recommend one or more of these to try to improve symptoms of chronic pain.

Hormone treatment

Endometriosis is sometimes called a hormone dependent condition. Oestrogen - one of the naturally-occurring hormones - causes endometriosis tissue to grow. Oestrogen levels are low before puberty and after the menopause but high in-between. There is some evidence that women with endometriosis have higher oestrogen levels than other women.

Hormone therapy generally works by reducing or controlling the amount of oestrogen in the body. It often temporarily reduces how much oestrogen the ovaries are producing.

The only definitive way to diagnose endometriosis is with an operation (laparoscopy). However, hormonal treatments - particularly contraceptives - are usually offered to women with possible endometriosis, if tests haven't shown any other causes for their symptoms. If the treatments work to control symptoms, it can avoid the need for an operation.

Hormonal treatments for endometriosis:

Combined hormonal contraception (birth control)

These contraceptive pills, patches, and vaginal rings contain a mixture of oestrogen and progesterone. They prevent ovulation from happening, and cause the lining of the womb to become thinner, making periods lighter and less painful - they have a similar effect on endometriosis tissue. Combined hormonal contraception can improve symptoms of pain, as well as pain during or after sex that's caused by endometriosis.

Combined hormonal contraception can be taken in the typical way - taking a 7-day break every month - which gives a monthly period. They can also be taken with the break taken every two or three months - reducing how often periods occur - or continuously without a break.

Taking continuously gives as few periods as possible but usually, after several months some light bleeding occurs. Taking a 4-day break when this occurs leads to a period, and bleeding stops again after restarting contraception.

Extended or continuous use of combined hormonal contraception is safe, may be more effective at preventing pregnancy than the typical way, and is a good option for women who want to have fewer periods - which includes some women with endometriosis.

Progesterone-only hormonal contraception

This includes the progesterone-only pill (minipill), the contraceptive injection, the contraceptive implant, and the intrauterine system - such as Mirena or Jaydess. These tend to cause light, irregular bleeding, although after a few months this tends to settle down and some women have no bleeding at all. All of these can reduce endometriosis-associated pain.

Other medication to lower oestrogen

Gonadotropin releasing hormone (GnRH) agonists (such as leuprorelin) and antagonists (such as elagolix) are special medications that block the hormones from the brain and reduce the amount of oestrogen that is produced by the ovaries. They are effective at reducing endometriosis symptoms. These are usually only considered if other hormone treatments haven't worked - they would be started by hospital specialists (gynaecologists).

These medications produce a temporary change that's similar to the menopause. As a result, they also have the side effect of producing menopausal symptoms, like vaginal dryness and hot flushes. With long-term use, they can lead to bone thinning (osteoporosis). To counteract these symptoms, sometimes these medications are given with 'add-back' hormone replacement therapy (HRT) to improve these symptoms and protect the bones.

Aromatase inhibitors (such as letrozole) are another specialist treatment. They also reduce oestrogen production but this time reducing the amount produced by the ovaries directly. They have side-effects similar to those above but these are often quite severe. So, these medications are generally only used if other medicines and surgery hasn't worked, or aren't an option.

Surgery

There are various different types of surgery for endometriosis which are done by gynaecologists who specialise in conditions affecting the female reproductive organs. They also work together with other surgeons, such as bowel surgeons and urologists, when doing operations on endometriosis affecting organs that those specialties deal with. Some gynaecologists have a special interest in endometriosis treatment and some women - particularly those with complex or severe endometriosis - may be referred to a specialist endometriosis centre for treatment.

Surgical treatments for endometriosis include:

Laparoscopy

During laparoscopy, a small telescopic camera is passed through a cut in the outside of the tummy (abdomen) so the surgeon can see the inside of the tummy and pelvis. This is the only way to definitively diagnose endometriosis, as it's the only test to see areas of endometriosis on the lining of the abdomen and other organs. It can also allow the surgeon to take a sample (biopsy) to help prove the diagnosis.
Treatment for endometriosis can also be done during a laparoscopy. Many surgeons will ask for consent to do this when performing a diagnostic laparoscopy, to avoid the need for two operations.

Hysterectomy

A hysterectomy - removal of the womb operation - may be offered to women for whom other treatments, including other surgeries, haven't worked. It's an irreversible procedure, and is only suitable for women who don't want to have children in future, as it makes future pregnancy impossible.

During a hysterectomy, the ovaries can also be removed (oophorectomy). Leaving the ovaries in place increases the risk of endometriosis coming back, making it more likely another operation will be needed. Removing the ovaries stops them producing oestrogen, which helps to shrink any endometriosis left behind. However, removing the ovaries causes permanent early menopause. Hormone replacement therapy (HRT) is usually advised to reduce the risk of osteoporosis and treat menopausal symptoms.

Other surgical techniques include:

• Removal (excision/cutting out) or destruction (ablation) of areas of endometriosis and endometriosis cysts.

• Cutting of adhesions - band-like scar tissue that forms between organs inside the pelvic cavity.

• Complex surgery to remove or destroy endometriosis tissue on other organs - such as the bowel or bladder. This is usually done as part of a team, which includes different types of surgeon - possibly bowel surgeons as well as gynaecologists.

Alternative treatments for endometriosis

Many people are keen to try different treatments for managing their endometriosis symptoms. This may be because other treatments haven't worked, or haven't appealed to them - for example, if the side-effects are severe.

There is little evidence as to whether alternative treatments in endometriosis work or not. However, some women might still want to try some of them.

• Acupuncture.

• Physiotherapy - such as pelvic physiotherapy and massage.

• Exercise - there's some evidence to suggest that regular exercise - at least three times a week, for around 45 to 60 minutes - reduces pain from periods. Although this research was done for general period pain, rather than specifically researching exercise in endometriosis.

• Psychological treatments - such as pain-focused psychotherapy and mindfulness.

• Dietary changes - some people have reported that changing their diet - for example, eating more antioxidants - helped their symptoms but there's not enough evidence to recommend any specific diet.

• A TENS machine for pain.

Fertility treatments

Fertility problems are more common in endometriosis, although not every woman is affected.

Hormonal treatments for endometriosis do not improve fertility. Hormonal contraceptives will prevent pregnancy during use, but they don't have any effect - positive or negative - on the chances of getting pregnant after being stopped.

Some surgical treatments for endometriosis - such as laparoscopic surgery - do seem to improve fertility.

Standard fertility treatments can also be used.

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Can endometriosis go away on its own?

Endometriosis symptoms usually improve, and may disappear, after menopause. Before then, endometriosis tends to get worse over time - but we don't know if this is the case for everyone, and there are some signs that, in some women, endometriosis tissue can shrink on its own. However, many women will need treatment to control the symptoms of endometriosis.

Deciding which treatment for endometriosis

Deciding on the right treatment for endometriosis depends on:

• Your own preferences - including how you feel about the benefits and risks, or side-effects, of treatment.

• Whether you want to get pregnant - now, or in the future.

• How severe the symptoms are.

• How much endometriosis is present and where it is.

• Which treatments have been tried so far.

Your doctor should be able to explain which treatments might work best for you, and what the benefits and risks are, to help you choose.

In general, most women with endometriosis - including those who possibly have it, but haven't had a laparoscopy to prove it - are recommended to try hormonal treatment, unless they are trying to get pregnant. There are lots of different options, and which one is right varies from person to person. The UK's National Institute for Health and Care Excellence's (NICE) decision aid shows the benefits and side-effects of different types of hormonal contraceptives in treating endometriosis, to help women choose the right option for them.

Hormonal treatment works for most, but not all, women.

Surgery isn't always required, but it is likely to be offered if:

• Endometriosis symptoms are severe.

• Endometriosis symptoms haven't improved or have reappeared, despite hormone therapy.

• There are signs or symptoms that endometriosis is affecting the bowels, bladder, or ureters - the tubes joining the kidneys to the bladder.

• There are signs of an endometriosis cyst on an ovary.

• Endometriosis is thought to be causing fertility problems.

Gynaecologists will be able to explain the benefits and risks of operations they suggest, to help you make an informed decision about whether to proceed.

Complications of endometriosis

Endometriosis can lead to several complications including:

• Difficulty getting pregnant (subfertility) or being unable to get pregnant at all (infertility).

• Ovarian cysts (endometriomas) - can affect fertility, and can also burst or rupture, causing sudden severe pain.

• Adhesions - band-like scar tissue that forms between organs. This can cause pain, and sometimes blockage of the bowel (bowel obstruction).

• Long lasting pain - can remain even after all areas of endometriosis have been surgically removed. See endometriosis causes for more information.

• Impaired quality of life - severe symptoms can substantially affect your quality of life. Endometriosis can lead to problems with sex, relationships, fitness, work, and many other parts of daily life.

• Emotional distress and mental health problems - a long-term painful condition can affect mental health, leading to distress, anxiety, and depression.

• Deposits of endometriosis tissue in other areas of the body - like inside the chest. This is rare, but can cause problems - for example, a collapsed lung. See uncommon symptoms of endometriosis for more detail.

• Ovarian cancer - several studies have reported an increased risk in women with endometriosis. However, the risk is still low - around 1.3% of women get ovarian cancer in their lifetime against 1.8% in women with endometriosis.