Endometriosis - Treating endometriosis

There is no cure for endometriosis and it can be difficult to treat. The aim of treatment is to ease the symptoms so that the condition does not interfere with your daily life.

Treatment will be given to relieve pain, slow the growth of endometriosis tissue, improve fertility and prevent the disease returning.

Deciding which treatment

Your gynaecologist will discuss the treatment options with you and outline the risks and benefits of each.

When deciding which treatment is right for you, there are several things to consider, including:

• your age
• whether your main symptom is pain or difficulty getting pregnant
• whether you want to become pregnant (some treatments may stop you getting pregnant)
• how you feel about surgery
• whether you have tried any of the treatments before

Treatment may not be necessary if your symptoms are mild and you have no fertility problems or if you are nearing the menopause, when symptoms may get better without treatment.

Endometriosis gets better by itself without treatment in about 3 in every 10 cases, but it becomes worse without treatment in about 4 in every 10 cases.

One course of action is to keep an eye on symptoms and decide to have treatment if they get worse.

Support from self-help groups, such as Endometriosis SHE Trust UK and Endometriosis UK, can be very useful if you are learning how to manage endometriosis.

Pain medication

Non-steroidal anti-inflammatories (NSAIDs), such as ibuprofen and naproxen, are usually the preferred painkiller used to treat the pain associated with endometriosis. This is because they act against the inflammation (swelling) caused by the condition, which may help ease pain and discomfort. It is best to take NSAIDs the day before (or several days before) you expect the period pain.

Paracetamol can be used to treat mild pain. It is not usually as effective as NSAIDs, but may be used if these types of drugs cause any side effects, such as nausea, vomiting and diarrhoea.

Codeine is a stronger painkiller that is sometimes combined with paracetamol or used alone if other painkillers are not suitable. However, constipation is a common side effect that may aggravate the symptoms of endometriosis.

For more information, read the Endometriosis UK factsheet on pain management for endometriosis.

Hormone treatments

The aim of hormone treatments is to limit or stop the production of oestrogen in your body. This is because oestrogen encourages endometriosis to grow and shed. Without exposure to oestrogen, the endometriosis tissue can be reduced, which helps ease the symptoms.

However, hormone treatment has no effect on adhesions ("sticky" areas of endometriosis that can cause organs to fuse together) and cannot improve fertility. Read more about adhesions and other complications of endometriosis.

Some of the main hormone-based treatments for endometriosis include:

• the combined oral contraceptive pill or contraceptive patch
• a levonorgestrel-releasing intrauterine system (LNG-IUS)
• gonadotrophin-releasing hormone (GnRH) analogues
• progestogens
• antiprogestogens

Evidence suggests these hormone treatments are equally effective in treating endometriosis, but they have different side effects. While they all impair fertility, only the contraceptive pill or patch and LNG-IUS are licensed to be used as contraceptives.

Progestogens and antiprogestogens are used less commonly these days because they often cause unpleasant side effects.

The combined oral contraceptive pill or patch

The combined contraceptive pill and contraceptive patch contain the hormones oestrogen and progestogen. They can help relieve milder symptoms and can be used over long periods of time. They stop eggs being released (ovulation) and make periods lighter and less painful.

These contraceptives can have side effects, but you can try different brands until you find one that suits you. Your doctor may recommend taking three packs of the pill in a row without a break to minimise the bleeding and improve any symptoms related to the bleeding.

Levonorgestrel-releasing intrauterine system (LNG-IUS)

The Mirena levonorgestrel-releasing intrauterine system (LNG-IUS) is a T-shaped contraceptive device that fits into the womb and releases a type of progestogen hormone called levonorgestrel.

This hormone prevents the lining of your womb growing quickly, which can help reduce pain and greatly reduces or even stops periods.

The device is put into the womb by a doctor or nurse. Once in place, it can remain effective for up to five years.

Possible side effects of using LNG-IUS include irregular bleeding that may last more than six months, breast tenderness and acne.

Gonadotrophin-releasing hormone (GnRH) analogues

GnRH analogues are synthetic hormones that bring on a temporary artificial menopause by reducing the production of oestrogen. They are usually taken as a nasal spray or injection.

Menopause-like side effects of GnRH analogues include hot flushes, vaginal dryness and low libido. Sometimes low doses of hormone replacement therapy (HRT) may be recommended in addition to GnRH analogues to prevent these side effects.

They are only prescribed on a short-term basis (normally a maximum of six months at a time) and your symptoms may return after treatment is stopped.

GnRH analogues are not licensed as a form of contraception, so you should still use contraception in the first month while taking them until they take full effect.

Examples of GnRH analogues include buserelin, goserelin, nafarelin and leuprorelin.

Progestogens

Progestogens, such as norethisterone, are synthetic hormones that behave like the natural hormone progesterone. They work by preventing the lining of your womb and any endometriosis tissue growing quickly.

However, they have side effects such as bloating, mood changes, irregular bleeding and weight gain.

Progestogens are usually taken daily in tablet form from days 5 to 26 of your menstrual cycle, counting the first day of your period as day one.

Progestogen tablets are not an effective form of contraception, so you will still need to use contraception while taking them if you don't want to get pregnant. 

Antiprogestogens

Also known as testosterone derivatives, antiprogestogens are synthetic hormones that work in a similar way to GnRH analogues. They bring on a temporary artificial menopause by decreasing the production of oestrogen.

Side effects of antiprogestogens can include weight gain, acne, mood changes and the development of masculine features such as hair growth and a deepening voice. As these side effects are often severe and alternative medications are more effective, antiprogestogens are no longer commonly prescribed.

Like GnRH analogues, antiprogestogens are usually only prescribed for a maximum of six months at a time.

Examples of antiprogestogens include danazol and gestrinone.

Surgery

Surgery can be used to remove or destroy areas of endometriosis tissue, which can help improve symptoms and fertility. The kind of surgery you have will depend on where the tissue is. The options are:

• laparoscopy (the most commonly used and least invasive technique)
• laparotomy
• hysterectomy

Any surgical procedure carries risks. It's important to discuss these with your surgeon before undergoing treatment.

Laparoscopic surgery

Laparoscopic surgery, also known as keyhole surgery, is a common procedure used to treat endometriosis. Small cuts (incisions) are made in your tummy so the endometriosis tissue can be destroyed or cut out.

Large incisions can be avoided because the surgeon uses an instrument called a laparoscope. This is a small tube that has a light source and a camera, which relays images of the inside of your tummy or pelvis to a television monitor.

During laparoscopic surgery, fine instruments are used to apply heat, a laser, an electric current (diathermy) or a beam of special helium gas to the patches of tissue to destroy or remove them.

The procedure is carried out under general anaesthetic, so you will be asleep during the procedure and won't feel any pain as it is carried out.

Ovarian cysts, or endometriomas, which are formed as a result of endometriosis, can also be removed using this technique.

Although this kind of surgery can relieve your symptoms and has been shown to improve fertility, problems can sometimes recur, especially if some endometriosis tissue is left behind.

Laparotomy

A laparotomy is a more invasive operation that is used if your endometriosis is severe and extensive or if endometriosis tissue has caused some of your organs to fuse together.

During the procedure, the surgeon makes a wide cut along the bikini line and opens up the area to access the affected organs and remove the endometriosis tissue.

Recovery time for this type of surgery is longer than for keyhole surgery.

Hysterectomy

If keyhole surgery and other treatments have not worked and you have decided not to have any more children, a hysterectomy (removal of the womb) can be an option. However, this is rarely required.

A hysterectomy is a major operation that will have a significant impact on your body. Deciding to have a hysterectomy is a big decision that you should discuss with your GP or gynaecologist.

Hysterectomies cannot be reversed and, though unlikely, there is no guarantee that the endometriosis symptoms will not return after the operation. If the ovaries are left in place, the endometriosis is more likely to return.

If your ovaries are removed during a hysterectomy, the possibility of needing HRT afterwards should be discussed with you. However, it is not clear what course of HRT is best for women who have endometriosis.

For example, oestrogen-only HRT may cause your symptoms to return if any endometriosis patches remain after the operation. This risk is reduced by the use of a combined course of HRT (oestrogen and progesterone), but this can increase your risk of developing breast cancer.

However, the risk of breast cancer is not significantly increased while you have not yet reached the normal age of the menopause. A decision about the recommended course of treatment will therefore need to be made on an individual basis.