Treatment of Endometriosis
At present, there is no definitive cure for endometriosis in the way that we understand cure as completely removing the disease such as treating appendicitis by removing the appendix or treating pneumonia by taking antibiotics to kill the bacteria causing it.
Treatments for endometriosis have the potential to reduce the disease and alleviate the symptoms associated with it. There is, however, the possibility that over time endometriosis related symptoms may return.
When to treat endometriosis
Endometriosis is a benign disease and doesn’t always require treatment.
The main reason to treat endometriosis is to alleviate its symptoms which, in some occasions, can be quite severe and debilitating.
The two main situations when treatment is considered are pain and infertility.
There are several options for the treatment of endometriosis
Endometriosis can be treated medically (with drugs), with surgery or a combination of both. Adjuvant therapies such as physiotherapy, physical exercise, healthy diet, weight loss and mindfulness have shown some positive effect in symptom reduction.
Treatment for pain
When pain is the main problem, the treatment aims to relieve symptoms and lessen the pain. The main treatments are:
Conservative management (no treatment)
The first option for treatment of benign, non life-threatening conditions is to do nothing. This option has to be considered on its pros and cons, as well as be compared to the risks and benefits of all the other options. In cases with mild or no pain or in women who are approaching menopause this could be the best option.
· no side effects of drugs
· no risks of surgery
· symptoms may improve on their own
· 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.
The main ones are:
Paracetamol (Panadol™, Panamax™)
Non-steroidal anti-inflammatory drugs (NSAIDs): Ibuprofen (Nurofen™, Advil™, Panafen™), Diclofenac (Voltaren™), Naproxen (Naprogesic™) Mefenamic Acid (Ponstan™).
· easy to get
· side effects uncommon
· 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.
As explained before, the growth of endometriotic cells is stimulated by hormones, most importantly the ones produced in 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 of changing the progression of endometriotic lesions and reducing pain symptoms.
Several studies have confirmed improvement of pain with hormone treatment with no particular option significantly better than the others.
Available in different formulations including:
Medroxyprogesterone (Provera ™ , Ralovera ™)
Norethisterone (Primolut N™)
Levonorgestrel (Microlut ™)
Medroxyprogesterone (Depo-Provera™, Depo-Ralovera ™)
Under skin implant
Etonogestrel (Implanon NXT™)
Levonorgestrel (Mirena ™)
· reduced pain
· lighter or no periods
· stops endometriosis growth in most cases
· some are contraceptive.
· side effects – may include weight gain, moodiness, acne, cramps, breast tenderness, irregular bleeding
· endometriosis symptoms may recur when treatment is stopped
· don’t always work for everyone
· doesn’t improve fertility
Combined oral contraceptive pill
Most of the pills commonly used for contraception can be used to reduce periods and period-related pain. They have been shown to reduce endometriosis pain and slow the progression of the disease.
There are several products in the market. They all contain an oestrogen and a progestogen which vary from brand to brand. Different pills are tolerated better or worse by different women. Sometimes, it is necessary to try two or three different ones to find the one that works best.
Vaginal contraceptive ring (NuvaRing™)
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 blood stream. The ring is replaced once every four weeks.
· reduced pain
· can be taken to reduce or stop periods
· does not require taking one tablet every day
· side effects – may include nausea, weight gain, mood changes
· doesn’t always work for everyone
Another way of treating endometriosis related pain is to completely stop ovarian activity. A group of drugs called GnRH (gonadotropin releasing hormone) analogues stops ovulation and the production of ovarian hormones. 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 oestrogen. Long term use can cause loss of bone density and oestrogen is required if the medication is used for more than 6 months.
The main commercially available compounds come in either a daily nasal spray self-administered by the patient Nafarelin (Synarelä) or monthly injection usually administered by a health professional, Goserelin (Zoladexä), Leuprorelin (Lupronä).
· very effective in reducing pain
· stops periods
· stops endometriosis growth in most cases
· side effects – menopause like symptoms, such as hot flushes and sweats
· need to add hormone replacement to prevent bone thinning if used for more than six months
· symptoms may recur when treatment is stopped
· doesn’t always work for everyone
Surgery for endometriosis is usually done via laparoscopy (keyhole surgery) and a laparotomy (open bigger incision) is rarely ever necessary these days.
The laparoscopy has two main objectives:
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).
Treatment of the 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 normalise pelvic anatomy so that the woman can fall 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 motions, consideration must be given to the removal of the affected segment of bowel. This is an uncommon situation and requires a specialised bowel surgeon working together with the gynaecologist.
Ongoing hormonal treatment, as described previously, is often used after surgery to enhance the reduction of symptoms and reduce the risk of endometriosis recurrence.
· the ability to make a definitive diagnosis
· long-term reduction of symptoms in up to 70% of women
· not all endometriosis can be treated this way
· there are risks associated with surgery
· a small number of women will not experience reduction in pain or will have recurrence of symptoms after a few months or years
Hysterectomy and removal of endometriosis
In a small group of women with severe symptoms that are not relieved by medical or surgical treatment, more extensive surgery such as a hysterectomy may be considered. This is particularly significant in women who have adenomyosis, a different form of endometriosis where the endometrium invades the muscular layer of the uterine walls.
Consideration of a woman’s desire for fertility is paramount as pregnancy is obviously not possible after such a procedure and a hysterectomy cannot be considered in women who still want to preserve their fertility.
· long-term symptom relief in over 90% of women
· remove the source of most new/recurrent endometriosis
· no need to use further medications
· no more periods.
· risks of surgery
· end of fertility
· potential psychological impact from losing an organ important to most women
· as with other treatments, there is no guarantee that the pain will be completely fixed
Alternative and complimentary therapies
There are various 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. The Pharmaceutical Benefits Scheme (PBS) does not cover the costs of alternative or complementary therapies.
Treatment for infertility
None of the medications described above has been shown to improve fertility and many of them are contraceptive therefore prevent pregnancy.
Some women who have endometriosis will fall pregnant on their own without any treatment which is therefore obviously not necessary.
After undergoing full investigation for other reasons for infertility in the couple, women 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 women with mild forms of the disease 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 main one being IVF (in vitro fertilisation).
3 - Surgery plus ART
Lastly, some women may require both surgery to remove the endometriosis and then IVF.
There is no option that suits everyone. Endometriosis presents in many different ways and various degrees of severity. Every woman is unique depending on age, severity of disease, 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.