Treatment:

There is no perfect way of managing endometriosis. The three basic treatment approaches are:

• Watchful waiting (to relieve symptoms)
• Hormonal therapy (to reduce the size of endometrial implants)
• Surgery (to reduce endometrial implants, restore fertility, or possibly cure the condition)

The choice depends on a number of factors, including the woman's symptoms, her age, whether fertility is a factor, and the severity of the disease.

Watchful Waiting

Delaying treatment may be most appropriate for women with mild endometriosis or those who are approaching the age of menopause.

Women may also use lifestyle modifications, such as exercise and relaxation, to cope with their pain. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil) and naproxen (Aleve), or acetaminophen (Tylenol), can help provide some pain relief.

Hormonal Therapy

Hormonal therapies are used to mimic states in which ovulation does not occur (such as pregnancy or menopause) or to directly block ovulation. Hormonal drugs include oral contraceptives, progestins, GnRH agonists, and danazol. They can be very effective in relieving endometriosis symptoms. Some of these drugs may also be used after surgery to help prevent recurrence of endometriosis. Downsides of these drugs include:

• None of these drugs can cure the problem. Symptoms recur in about half of patients within 5 years of treatment.
• They do not improve fertility rates and may delay conception.
• Side effects of these drugs can be distressing. There is a high dropout rate with the use of nearly all of these hormonal treatments.
• Women who take GnRH agonists, danazol, or similar drugs should use non-hormonal birth control methods (such as the diaphragm, cervical cap, or condoms) because these drugs can increase the risk for birth defects.

Surgery

Surgery is an option for women who:

• Have severe pain that does not respond to watchful waiting and medical treatment.
• Want to become pregnant and endometriosis is most likely the major contributor to infertility.

There are two basic surgical approaches for endometriosis:

• Conservative Surgery (Laparoscopy or Laparotomy). Conservative surgery uses minimally invasive laparoscopy, or sometimes laparotomy (conventional “open” surgery through normal incision), to remove the endometriosis implants without removing any normal tissue or reproductive organs. It is a good option for women who wish to become pregnant or who cannot tolerate hormone therapy. Endometriosis often recurs after conservative surgery, however. The risk for recurrence or residual pain after any procedure increases with the severity of the condition, particularly if endometriosis has affected areas outside the uterus.
• Radical Surgery (Hysterectomy). Hysterectomy offers the best option for either a cure or more significant control of the problem. Younger patients can often have only a hysterectomy while leaving one or both of their ovaries intact. However, if endometriosis has developed outside the uterus then even this procedure is not curative. Removing only the uterus with hysterectomy has the same risk for recurrence as conservative surgery. Removing both ovaries (bilateral oophorectomy) along with the uterus is the only potential cure for endometriosis.

In choosing between hysterectomy (with or without removal of the ovaries) and conservative surgeries, age and the desire for children are important factors.

Treating Infertility in Patients with Endometriosis

For women with severe endometriosis who want to become pregnant, conservative surgery (typically laparoscopy) is the appropriate approach for restoring fertility. Hormonal therapies that treat endometriosis itself, such as GnRH agonist or progestins, generally do not help fertility. If surgery fails, fertility drugs and artificial reproductive technologies, such as in vitro fertilization, are options. Women with endometriosis who are trying to conceive should discuss all treatment options with a fertility specialist. [For more information, see In-Depth Report #22: Infertility in women.]