Treatment options for endometriosis
Although there is currently no cure for endometriosis, various things can be done to relieve the symptoms and improve quality of life. The choice of treatment mainly depends on whether the woman would like to become pregnant.
A woman’s choice of endometriosis treatment will greatly depend on her personal situation. If symptoms like pain and cramping are the main problem, many different symptom-relieving treatments can be considered. These include painkillers, hormones or surgery. Hormone treatment isn't suitable for women who would like to become pregnant, though.
None of the available treatments are a guaranteed cure. It often takes some time before women find a treatment that provides enough symptom relief and has side effects that are acceptable to them.
Treatment with medication
Treatment with medication mainly aims to relieve or stop bad pain and cramps around the time of the woman’s monthly period. This can be done using painkillers and hormone drugs that suppress ovulation (stop eggs from being released from the ovaries). If a woman has recurring, but not extremely bad, pain in her abdomen (lower belly), painkillers or hormonal contraceptives like “the pill” can provide noticeable relief. These medications are often very well tolerated and are therefore usually suitable for young women who have endometriosis. If they don't relieve the symptoms enough, stronger medications can be considered.
A group of painkillers known as non-steroidal anti-inflammatory drugs (NSAIDs) are often used to treat period pain, as well as endometriosis. These painkillers include ibuprofen, diclofenac and acetylsalicylic acid (ASA – the drug in medicines like Aspirin). Some of these drugs can be bought “over the counter” in pharmacies, others are only available on prescription, particularly if taken in higher doses.
NSAIDs can provide effective period pain relief and are usually well tolerated. But there is hardly any research on whether they also help relieve pain caused by endometriosis. These medications can cause side effects such as stomach problems, nausea and headaches. ASA also prevents blood from coagulating (clotting). For these reasons, people shouldn't take painkillers frequently or over long periods of time without consulting their doctor.
If women have more severe pain, drugs known as opioids are sometimes used too. Opioids act in a similar way to pain-relieving substances made in the body, influencing pain perception in the brain. These drugs are only allowed to be used if prescribed by a doctor. There is a risk of becoming dependent on them, particularly stronger kinds, if they are taken for long periods of time. Possible side effects include nausea, vomiting, constipation, tiredness, dizziness and changes in blood pressure. There is currently no reliable research on the effectiveness of these painkillers in the treatment of endometriosis.
Hormone-based drugs suppress the production of hormones in women’s ovaries, preventing ovulation (the release of eggs) and their monthly period. They aren't suitable for women who would like to become pregnant. Hormone treatments used in endometriosis include:
- particular drugs that prevent ovulation, such as the pill or contraceptive patch,
- GnRH analogues (agonists), and
- androgenic substances.
Hormone treatments can prevent the mucous membranes in endometrial implants (endometriosis tissue) from building up, and this can relieve the pain. It's not clear whether these medications can also make the endometrial implants get smaller or disappear completely, though. Endometriosis symptoms often return when women stop hormone therapy. Contraceptives like the pill, contraceptive patch, birth control implant and progestins are suitable for use in long-term hormone therapy.
The birth control pill
Most contraceptive pills have been proven to relieve endometriosis-related pain. But if a woman has bad period pain (dysmenorrhea), the period-like bleeding at the end of a pill cycle – known as withdrawal bleeding – can still be painful. The main side effects of the pill include headaches, fluid retention and breast tenderness.
Some types of contraceptive pill can be used to suppress a woman’s monthly hormone cycle and period for a longer amount of time too. To do so, they are taken continuously, without any breaks – or with less frequent breaks – between cycles. The continuous use of the pill is sometimes referred to as an “extended-cycle regimen.” Because this way of using the pill hasn't been approved in Germany, it is considered to be “off-label use” (non-approved use). Drugs which are used off-label might not be covered by health insurance funds in Germany.
GnRH analogues (agonists)
Hormone drugs known as GnRH (gonadotropin-releasing hormone) analogues or GnRH agonists can relieve endometriosis symptoms too. But they have stronger side effects than the pill: They reduce the production of female sex hormones so much that they often cause problems related to estrogen deficiency. These are similar to the problems women may have during menopause, such as hot flashes, sleep problems, vaginal dryness and mood swings.
When used over longer periods of time, GnRH analogues may also reduce women’s bone density. Research suggests that their bone density returns to normal within two years of stopping this treatment. If a woman uses GnRH analogues for longer than six months, she can also start hormone therapy with low doses of estrogen at the same time. This approach is called “add-back therapy” and aims to reduce problems associated with estrogen deficiency.
Progestins and the LNG-IUS
Drugs containing the hormone progestin also relieve pain in endometriosis. Progestins can have side effects like spotting (light period-like bleeding between cycles), weight gain, feeling down and reduced sexual desire.
There is a progestin-containing coil (the LNG-IUS, short for levonorgestrel-releasing intrauterine system) which can be inserted into the womb. In the treatment of endometriosis, the LNG-IUS has only been studied as an additional treatment to surgery. When combined with surgery, it can relieve endometriosis symptoms better than surgery alone. The LNG-IUS is also used as a contraceptive. This has been shown to cause side effects such as spotting, abdominal pain, headaches and breast tenderness.
Danazol, a drug that is similar to the male sex hormone testosterone, is no longer available in Germany because it can have severe side effects.
Generally speaking, endometriosis can be treated surgically using a relatively gentle procedure called a laparoscopy. Alternatively, a surgical procedure known as laparotomy, which involves cutting through the wall of the abdomen (tummy), may be carried out instead. In both approaches, the endometrial implants are removed under general anesthesia using heat – either produced by a laser or an electric current running through a probe (diathermy). It isn't clear whether one of these approaches is better than the other.
The surgical removal of endometrial implants and endometriosis-related cysts in the ovaries (endometriomas) appears to relieve pain in mild to moderate endometriosis. Research suggests that removing endometrial implants during a laparoscopy can also improve fertility somewhat.
In about 20 out of 100 women, though, endometrial implants grow again within five years of surgery. This can cause endometriosis-related problems again too. In about 1 out of 100 women, the surgery leads to organ injuries or other complications such as infections or heavy bleeding.
Severe endometriosis that also affects the bowel and/or bladder is rare. Too little research has been done to be able to say for sure which of the surgical treatment approaches is most effective in this kind of endometriosis.
Procedures such as “laparoscopic uterine nerve ablation” (LUNA) are sometimes used in women who have very severe symptoms. LUNA is carried out during laparoscopic surgery and involves cutting nerve fibers in the womb that carry pain signals. According to current research, though, it appears that this procedure doesn't relieve symptoms like period pain and pain during or after sex.
Medication before and after laparoscopy
Sometimes doctors suggest that women take additional hormones before or after having a laparoscopy. This is meant to shrink endometrial implants, as well as possibly reduce the activity of endometrial tissue which hasn't been removed and prevent new tissue from growing. But research hasn't found this combination of medication and laparoscopic surgery to have any advantages over laparoscopic surgery alone: It didn't reduce pain or improve women’s chances of getting pregnant. Some studies found that women had more side effects if they also took the medication, though.
Removal of the womb and ovaries
If women have endometrial implants in their womb, and these are causing severe symptoms, they may consider having surgery to remove their womb (a hysterectomy). Endometrial implants near to the womb can be removed at the same time.
Most women only consider having a hysterectomy if their endometriosis is a real problem in everyday life, other treatments have failed, and they are sure that they don't want to have any (more) children. The woman’s age plays an important role when deciding whether or not to have a hysterectomy. And having this kind of surgery only makes sense if it is likely to lead to an improvement in symptoms.
Removing the womb alone doesn't guarantee that the endometriosis will be gone afterwards. If the fallopian tubes and ovaries aren't removed too, women might still have endometriosis symptoms. So they are faced with another difficult decision: Removing both ovaries causes the production of female sex hormones to stop, leading to sudden early menopause. Menopause normally starts between the ages of 40 and 50. The average age at which women have their last period is 51.
Women who have their womb removed usually don't also have their ovaries removed, to keep up the production of hormones.
If the ovaries are removed too, then any remaining endometrial implants in the body stop getting the hormones they need to grow. But the general problems caused by the drop in hormones after this operation can be so severe that some women decide to take estrogen. This hormone therapy might make the endometriosis symptoms return.
As with all surgical procedures done using an anesthetic, surgery for endometriosis can also lead to complications like organ damage, bleeding or infections. These occur in about 5 out of 100 women.
Other treatments for pain relief
Because none of the treatments for endometriosis are guaranteed to work and they all have potential disadvantages, many women try out various products and methods – including those that are said to help relieve period pain. But there is no reliable proof that the “complementary” or alternative medicine approaches and relaxation techniques described below can relieve endometriosis symptoms. Some of them, for instance particular herbal products, can have side effects too.
Many of them take up a lot of time and you have to pay for them yourself. Others simply give women the opportunity to relax and do something they enjoy. The approaches that haven't been reliably proven to relieve endometriosis symptoms include:
- Herbal products, acupuncture and homeopathy.
- “Transcutaneous electrical nerve stimulation” (TENS): This aims to influence pain perception using small electric currents.
- General relaxation exercises, or techniques like yoga or tai chi.
- Procedures such as chiropractic treatment, relaxation techniques and pain management training.
- Lifestyle changes such as getting more exercise, reducing stress or changing your diet.
Household remedies like applying heat (for example by using hot water bottles, heat packs or taking a warm bath) help to reduce pain in some women. They find that heat has a relaxing, soothing effect and relieves cramps.
Options for women who would like to become pregnant
Women are considered to have fertility problems if they have not become pregnant after having regular unprotected sex for a year. There are many possible reasons for infertility. Endometrial implants affecting the function of the ovaries and fallopian tubes is just one of them.
If a woman who has endometriosis would like to get pregnant, hormone therapy is not a treatment option. This is because hormone therapy either has a contraceptive effect or greatly reduces the chances of becoming pregnant.
So the treatment options for women who would like to have (more) children include painkillers and laparoscopic surgery to remove as many endometrial implants as possible. Research suggests that laparoscopic surgery to remove visible endometrial implants and cysts in women with severe endometriosis can increase their chances of getting pregnant naturally. There is also some evidence that surgically removing endometrial implants from the ovaries increases the chances of becoming pregnant too.
In milder forms of endometriosis, where the ovaries and fallopian tubes are not affected, it is not clear whether endometrial implants reduce fertility at all. So it is also not clear whether surgery would help in this case.
Infertility can be treated with medications that help eggs to mature and be released (ovulation) or medications that influence the hormone progesterone. This kind of hormone therapy stimulates the function of the ovaries.
If it doesn't work, IVF (in vitro fertilization) treatment may be considered. This treatment involves taking egg cells from the woman’s ovaries, and then preparing the egg cells and exposing them to the man’s sperm in a laboratory. Any fertilized eggs are later placed inside the woman’s womb. The chances of IVF being successful are somewhat lower in women who have a severe form of endometriosis than they are in women who don't have endometriosis.
A second medical opinion can help if you're not sure
If you still feel unsure about what treatment is most suitable – even after consulting a doctor and possibly getting a recommendation for a particular treatment – you can get a second medical opinion. This can be a particularly good idea if a hysterectomy (surgery to remove the womb) is recommended. The most suitable choice of treatment will not only depend on your medical circumstances, but also very much on your individual situation and preferences. Our decision aid may help here. It briefly summarizes and compares the main pros and cons of the different treatments.
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