Treatment options for endometriosis

A group of painkillers known as non-steroidal anti-inflammatory drugs (NSAIDs) are often used to treat endometriosis. These painkillers include ibuprofen, diclofenac and acetylsalicylic acid (the drug in medicines like Aspirin). Lower doses of these drugs can be bought “over the counter” in pharmacies. Higher doses are only available on prescription.

NSAIDs can provide effective period pain relief and are usually well tolerated. But they sometimes cause side effects such as stomach problems, nausea and headaches. Acetylsalicylic acid ("Aspirin") also reduces blood clotting (coagulation). For these reasons, people shouldn't take painkillers frequently or over long periods of time without consulting their doctor.

If women have chronic pain, drugs known as opioids are sometimes used too. But opioids are rarely used in the treatment of endometriosis, partly because the symptoms typically only occur during the monthly period. 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. If opioids are taken over long periods of time, there is a risk of becoming dependent on them – particularly stronger kinds. 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:

• Progestins
• The birth control pill (contraceptive pill)
• GnRH analogues (agonists)

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.

Drugs containing the hormone progestin also relieve pain in endometriosis. They are often the treatment of first choice for 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 that can be inserted into the womb. It is known as the LNG-IUS, short for levonorgestrel-releasing intrauterine system. In the treatment of endometriosis, the LNG-IUS has only been studied as a treatment that is used after surgery. When used in this way, 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, acne and breast tenderness.

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 between cycles (continuous use) – or with less frequent breaks (extended use). 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 that are used off-label might not be covered by health insurance funds in Germany.

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 does: 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. Because of this, women who use GnRH analogues are advised to take low doses of estrogen at the same time. Known as “add-back therapy,” this approach aims to reduce problems associated with estrogen deficiency.

Generally speaking, endometriosis can be treated surgically using a relatively gentle procedure called a laparoscopy. Alternatively, a surgical procedure known as laparotomy can be carried out instead. This involves cutting through the wall of the abdomen (tummy).

In both approaches, the endometrial implants are removed under general anesthesia using a scalpel or heat – either produced by a laser or an electric current running through a probe (diathermy).

The surgical removal of endometrial implants and endometriosis cysts in the ovaries (endometriomas) can relieve pain in mild to moderate endometriosis. It's not clear whether removing endometrial implants during a laparoscopy can also improve fertility somewhat. Studies have suggested that it does, but there's an overall lack of good research in this area.

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.

Sometimes doctors suggest that women take certain hormones before and/or after having a laparoscopy. This is meant to shrink endometrial implants, as well as possibly reduce the activity of endometrial tissue that hasn't been removed and prevent new tissue from growing. Research suggests that using hormones after the surgery reduces the risk of the endometriosis coming back. But using hormones before the surgery has not been proven to have any benefits.

If women have endometriosis in their womb, and it is 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 as well, women might still have endometriosis symptoms.

If the ovaries are removed too, then any remaining endometrial implants in the body stop getting the hormones they need to grow. But 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. So it's important to carefully consider the pros and cons of removing the ovaries before making a decision. If only one of the ovaries is removed, it won't affect the production of hormones.

In some women, the problems caused by the drop in hormones after surgery are so severe that they wish to take estrogen (hormone replacement therapy, or HRT). This hormone therapy might make the endometriosis symptoms return.

As with all surgical procedures, surgery for endometriosis can lead to complications like organ damage, bleeding or infections.

None of the treatments for endometriosis are guaranteed to work and they all have potential side effects. Many women try out other approaches because of this, including complementary medicine treatments such as herbal products, dietary supplements, homeopathy and acupuncture. But there's no proof that these treatments can relieve endometriosis symptoms. Most of them haven't been tested in good-quality studies.

The same is true for special diets, yoga, relaxation techniques and doing more exercise and sports. But lifestyle changes can reduce stress and improve your physical fitness and wellbeing. Some women try to relieve period pain with household remedies such as hot water bottles, heat packs or taking a warm bath. They find that the heat has a relaxing, soothing effect and reduces their cramps.

Women are considered to have fertility problems if they haven't 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's not clear whether endometrial implants reduce fertility at all. So it's 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 that 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 adding the man’s sperm to them 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.

There are also “endometriosis centers” where a number of different specially trained healthcare professionals work together. These centers are certified as such based on specific criteria. They aim to offer women treatment packages tailored to their own personal situation and symptoms. The treatments may include medication, surgery and psychological support. But you can also get treatment for endometriosis in a normal gynecology (ObGyn) practice.

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 go to a different doctor for 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.