Endometriosis: What are my treatment options?

If you're still unsure of what endometriosis is and/or how it's diagnosed start here.

Treatment for endometriosis normally falls into three categories:

1. Medical treatments: medication
2. Surgical treatments: laparoscope/operations
3. Complementary therapies: lifestyle changes, physiotherapy, psychology, naturopathy, kinesiology, acupuncture, herbalists, nutritionists, etc.

 

Let’s look at what these might involve:

Medical treatments:

This can be further divided into non-hormonal and hormonal management:

Hormonal: this may include things like the oral contraceptive pill or progestin based hormonal contraceptives, like the IUD or Rod. Gonadotrophin hormone releasing drugs may also be used. These may help with some pain caused by endometriosis.

• Oral contraceptive pills (OCP) may work by suppressing oestrogen and ovulation and therefore one of the proposed mechanisms of pain in endometriosis. They may not be effective for everyone, and medication choice is a very individual decision, and you should discuss this with a trusted health care provider.
• Progestin only contraceptives are often better tolerated than the OCP (3) and have been reported in some studies to reduce pain in 70-100% of users on devices like the IUD. An randomised controlled trial completed in 2003 found that after laparoscopic surgery, the use of an IUD was more effective than no IUD at reducing symptoms of menstrual pain (dysmenorrhea) and shown to have a significant decrease in the extent of lesions observed at second look laparoscopy after 6 months (4).
  Again, medication choice is something that is very individual and should be discussed with your health care provider.
• Gonadotrophin hormone releasing (GnRH) analogues can be helpful to turn off ovarian function and therefore may result in symptomatic relief of the pain symptoms of endometriosis. This is often a short-term solution and comes with side effects like the development of menopausal symptoms and the loss of bone mineral density with long term use (5). 

Non-hormonal: this may look like using medications such as paracetamol, non-steroidal anti-inflammatories and stronger pain relievers prescribed by your health care provider.

• NSAIDS: the use of non-steroidal anti-inflammatory drugs (like nurofen) can help to decrease the production of prostaglandins which can contribute to endometriosis related inflammation and pain. Anti-prostaglandin agents have been shown to be effective for treatment of period pain (primary dysmenorrhea), however there is no evidence specifically for endometriosis pain (6).

**NOTE: This is general information only and should not replace medical advice. If you have any concerns or are unsure, please speak to your health care provider. 

Surgical treatments:

Surgical treatment is currently the gold standard treatment for endometriosis. A 2009 meta-analysis showed a statistically significant benefit of laparoscopic surgery as an effective treatment for pain due to endometriosis when compared to diagnostic laparoscopy alone (5). Multiple studies (5, 7-9) have shown that pain related to endometriosis significantly decreased after surgical excision. Studies have also shown that quality of life scores (self-reported) increase after excision surgery as well as an improvement in non-menstrual pelvic pain and dyspareunia (pain with sex) for a period of up to 5 years post-operatively (5).

This is something that an individual with endometriosis symptoms needs to discuss with their trusted health care provider, as the timing of laparoscopy is important and often medical and lifestyle management will be the first line of treatment, so that surgery can be delayed. Research has shown that the most important factor that influences the chances of a woman having a repeat operation is the age of the women at presentation for primary surgery. Women presenting at a younger age group (<30 years old) were more likely to have a repeat operation later in life (10).

 

Other treatment options:

Endometriosis very much requires a collaborative team approach and other professionals who may form part of a multi-disciplinary team (MDT) may include: physiotherapists, naturopath, psychologist, acupuncturist, herbalists and nutritionists to name a few. Lifestyle modifications form a big part of the treatment for endometriosis, looking at things like exercise, diet, mindfulness, sleep and stress.

 

Pelvic Floor Physiotherapy:

Pelvic Floor Physiotherapists are health care professionals that can help you understand your symptoms and treat the central nervous systems response to pain. Pelvic Floor Physiotherapists can help with the following:

• Treat the musculoskeletal system that may be reacting to prolonged and severe pain (glutes, adductors, pelvic floor, abdominals etc)
• Help sex be less painful (if that is a symptom)
• Provide education, support and information about endometriosis
• Give bladder and bowel advice and treat things like constipation and painful bladder and bowels motions.
• Provide you with self-management strategies to manage flare ups
• Provide exercise advice and guidance
• Help to relax your pelvic floor – which can treat things like vulvodynia, vaginismus and pudendal neuralgia 

Studies have shown that musculoskeletal factors can exacerbate endometriosis symptoms and have shown pelvic floor physiotherapy in conjunction with other interventions like dietary and lifestyle changes, to be effective (11). Additionally, mindfulness strategies and breath work can also be effective (12). A study done in 2019 on self-management strategies found that 47% of people with endometriosis used breathing exercises and meditation as a part of their pain management (13). The same study also found yoga/pilates to be effective, but to a lesser extent (13). Regardless of the exercise chosen by the person with endometriosis, they need to enjoy it and believe that it is helping them and not making them worse. What you think about your treatment can have an impact on how well the treatment will work! 

 

 

These resources may be helpful to you if you currently suffer with endometriosis:

• How can dilators help with painful sex?
• Painful sex - what causes it?
• Pain in the bladder: why it hurts to urinate
• What is Pudendal Neuralgia?
• What and where is your pelvic floor?
• Pelvic Pain Mobility

 

References:

1. Parasar P, Ozcan P, Terry KL. Endometriosis: epidemiology, diagnosis and clinical management. Current obstetrics and gynecology reports. 2017;6(1):34-41.
2. Nisolle M, Donnez J. Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities. Fertility and sterility. 1997;68(4):585-96.
3. Meresman GF, Augé L, Barañao RI, Lombardi E, Tesone M, Sueldo C. Oral contraceptives suppress cell proliferation and enhance apoptosis of eutopic endometrial tissue from patients with endometriosis. Fertility and sterility. 2002;77(6):1141-7.
4. Vercellini P, Frontino G, De Giorgi O, Aimi G, Zaina B, Crosignani PG. Comparison of a levonorgestrel-releasing intrauterine device versus expectant management after conservative surgery for symptomatic endometriosis: a pilot study. Fertility and sterility. 2003;80(2):305-9.
5. Jacobson TZ, Duffy JM, Barlow DH, Koninckx PR, Garry R. Laparoscopic surgery for pelvic pain associated with endometriosis. Cochrane Database of Systematic Reviews. 2009(4).
6. Marjoribanks J, Proctor M, Farquhar C, Sangkomkamhang US, Derks RS. Nonsteroidal anti‐inflammatory drugs for primary dysmenorrhoea. Cochrane Database of Systematic Reviews. 2003(4).
7. Abbott J, Hawe J, Clayton R, Garry R. The effects and effectiveness of laparoscopic excision of endometriosis: a prospective study with 2–5 year follow‐up. Human Reproduction. 2003;18(9):1922-7.
8. Chopin N, Vieira M, Borghese B, Foulot H, Dousset B, Coste J, et al. Operative management of deeply infiltrating endometriosis: results on pelvic pain symptoms according to a surgical classification. Journal of minimally invasive gynecology. 2005;12(2):106-12.
9. Roman H, Quibel S, Auber M, Muszynski H, Huet E, Marpeau L, et al. Recurrences and fertility after endometrioma ablation in women with and without colorectal endometriosis: a prospective cohort study. Human Reproduction. 2015;30(3):558-68.
10. De Ziegler D, Borghese B, Chapron C. Endometriosis and infertility: pathophysiology and management. The Lancet. 2010;376(9742):730-8.
11. Vandyken C, Hilton S. Physical therapy in the treatment of central pain mechanisms for female sexual pain. Sexual medicine reviews. 2017;5(1):20-30.
12. Rosenbaum TY. An integrated mindfulness-based approach to the treatment of women with sexual pain and anxiety: Promoting autonomy and mind/body connection. Sexual and Relationship Therapy. 2013;28(1-2):20-8.
13. Armour M, Sinclair J, Chalmers KJ, Smith CA. Self-management strategies amongst Australian women with endometriosis: a national online survey. BMC complementary and alternative medicine. 2019;19(1):1-8.
14. Proctor M, Farquhar C. Diagnosis and management of dysmenorrhoea. Bmj. 2006;332(7550):1134-8.