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Management & treatment

There are many options for managing and treating endometriosis, including a healthy lifestyle, pain-relief medications, hormone therapy such as the combined oral contraceptive pill and progestins. Different types of surgery, including laparoscopy, laparotomy and hysterectomy, are also discussed.

It is not OK to have severe period pain. If the pain is so severe that you are missing school, work and other activities, seek help.

If you suspect you have endometriosis, see your health care practitioner, who can refer you to a specialist gynaecologist.

Many women with endometriosis are cared for by a team of health professionals including their doctor, a gynaecologist who specialises in the area, a psychologist, medical sex therapist, pain specialist, colorectal surgeon and urologist.

The right treatment for you will depend on your symptoms, the severity of the condition and whether you are trying to become pregnant or maintain your ability to have children.

Topics on this page

There is no direct evidence that a healthy lifestyle reduces the severity of endometriosis; however, it is important to strive to be as healthy as possible.

Here are some things you can do and how they may help:

Physical activity and exercise Some gentle activity to keep your body moving can help to ease pain. About 20-30 minutes of physical exercise on most days of the week is recommended, unless you have not exercised recently. If that is the case, you should begin with smaller amounts and gradually build up as your fitness improves
Sleep Having enough quality sleep every night will help your immune system function at its best. - Reduce caffeine and alcohol intake late at night - Avoid heavy meals late at night - Maintain regular timing for going to bed and waking
Stress management and relaxation Finding ways to manage the stress that endometriosis can create is important for your wellbeing. - Try gentle yoga techniques - Try relaxation skills such as mindfulness therapy - Organise your day so you always have some time out for yourself - Seek help from a psychologist or counsellor

Endometriosis & natural therapies

Many women in Australia with endometriosis use natural and complementary therapies to manage their symptoms and improve quality of life.

Research shows that women with endometriosis are more likely to use natural therapies, or see a natural therapist, compared to women who do not have endometriosis.

With endometriosis, natural therapies are often used to help manage a particular symptom, such as period pain or fertility issues. Treatment may also focus on typical features of the condition; for example, inflammation.

Despite the popular use of natural therapies in endometriosis management – and the many remedies and treatments promoted for the condition – there is unfortunately a lack of good quality research in the area.

Read more about these treatments and the research findings at Endometriosis & natural therapies.

Managing endometriosis with pain relief medicines

Managing the pain from endometriosis usually involves:

  • medication for pain relief, such as non-steroidal anti-inflammatory drugs (NSAIDs)
  • hormone therapy, such as the combined oral contraceptive pill (you do not have to be sexually active to take this).

Managing endometriosis with hormone therapy

Hormone therapies may be used as a treatment for many stages of endometriosis, or as a combined therapy, either before or after surgery, for minimal to severe endometriosis.

Hormone therapies aim to reduce pain and the severity of the endometriosis by:

  • suppressing the growth of endometrial cells
  • stopping any bleeding, including the period.

Hormone therapies include:

Combined oral contraceptive pill (COCP)
The combined oral contraceptive pill (COCP) is taken continuously, by skipping the sugar (hormone-free) pills. Better pain relief and cessation of periods occurs with the continuous pill. You do not have to be sexually active to take the COCP. The pill is taken to: - stop your period, or reduce the number of periods you have in a year suppress endometriosis; - provide long-term relief from period pain that is not helped with - non-steroidal anti-inflammatory drugs (NSAIDs). The pill may slow the progression of endometriosis. The pill also provides contraception if that is required. Possible side effects include: - irregular bleeding - nausea - abdominal bloating - breast tenderness - weight gain - mood changes/depression - headache. More serious risks of the pill, such as blood clots (thrombosis), are rare. If you experience chest pain, severe headaches, severe pain or swelling of your leg, you should see your doctor immediately. You should not take the pill if you: - smoke and/or are over the age of 35 with risk factors for heart disease or cardiovascular disease - have high blood pressure - have had recent breast cancer, deep vein thrombosis, heart attack or stroke - have liver disease - have a family history of thrombosis or clots.
Progestogens – both naturally occurring and synthetic forms of progesterone (progestins)
Progestogens provide pain relief for up to 80% of women with endometriosis. It is not known exactly how progestogens relieve the symptoms of endometriosis, but it is believed they suppress the growth of the endometrial tissue in some way, causing them to shrink gradually and eventually disappear. There are oral forms that are taken daily or long-acting forms given through injection, implant or IUD (intrauterine device). Possible side effects include: - irregular bleeding - breast tenderness - acne - abdominal bloating - fluid retention - mood changes/depression - nausea/vomiting - dizziness - tiredness - weight gain.
GnRH agonists and antagonists – modified versions of gonadotrophin-releasing hormone (GnRH), a naturally occurring hormone that stops/suppresses the menstrual cycle.
The GnRH agonists reduce or eradicate endometrial implants by suppressing ovulation and the production of oestrogen and progesterone by the ovaries. The low levels of oestrogen in the body mean the endometrial implants are no longer stimulated to grow, and they break down each month so they gradually shrink or 'dry up'. This creates a temporary chemical 'menopause'. This method is usually used for moderate to severe endometriosis. It is as effective as other medical therapies and may be used pre or post-surgery. These are powerful medications and are often associated with side effects. These side effects may be reduced by taking additional medications. The most commonly reported side effects are those associated with menopause, which include: - hot flushes/night sweats - vaginal dryness - mood changes/depression - acne - muscle pains - decreased breast size. GnRH antagonists are currently unavailable in Australia. The GnRH agonists and antagonists may cause a marked decrease in bone density (thinning of the bones). However, much of this loss of bone density is reversed within six months of completing treatment and is usually completely or almost completely reversed within 12-18 months of completing treatment. Nevertheless, this loss of bone density can be serious as it can predispose you to osteoporosis. Oestrogen therapy is often prescribed to alleviate the menopause symptoms and stop bone loss. Discuss with your doctor whether or not you need a bone density scan (DXA) before beginning treatment.
Pill packet

Danazol is another synthetic hormone used to aid pain relief. Danazol is infrequently prescribed because it can have many side effects, particularly testosterone-like side effects such as acne, oily skin/hair, increased facial/body hair and deepening of the voice.

Combined treatments

Combined treatments involve a course of hormone treatment, before or after surgery, to enhance the effects of the surgery.

Hormone therapy may be used prior to surgery to shrink the size of endometriomas and endometriotic implants.

Some studies have shown there is a delay in the return of endometrial pain if the surgery is followed by treatment with:

  • GnRH agonists
  • the Mirena® intrauterine device (IUD)
  • the oral contraceptive pill.

Treating endometriosis with surgery

Surgery for endometriosis aims to remove as much visible endometriosis as possible and to repair any damage caused by the condition. Endometriosis is seen as implants (patches of endometriosis), cysts, nodules, endometriomas (chocolate cysts) and adhesions.

Laparoscopy

Laparoscopic surgery is keyhole surgery performed under general anaesthetic, in which a thin telescope with a light (laparoscope) is inserted into the abdominal cavity. This allows the gynaecologist to see if there is any endometrial tissue within the pelvis. The operation aims to reduce symptoms and improve fertility by removing endometrial tissue. This tissue can be endometriotic patches, implants, cysts, nodules and adhesions.

If endometrial tissue is found in the abdominal cavity, it can be removed by vapourising (destroying cells with electrical energy) or excising it (cutting it away). The method used depends on the tissue's location. Both methods have been shown to improve pain in the short and longer term. It is important to note that it is not how the disease is removed, but rather that all the disease is removed that is important to improving the symptoms.

Laparoscopy can also be used to:

  • remove large cysts and endometriomas
  • remove an ovary/ovaries and/or (fallopian) tubes
  • surgically repair any damaged organs.

Laparotomy

A laparotomy is an open operation requiring a larger cut in the lower belly. It may be performed if endometriosis is severe and extensive, or if laparoscopic surgery is not an option. It is recommended that women with severe endometriosis be referred to a specialised clinic for the most appropriate surgical management.

Hysterectomy

Hysterectomy is recommended rarely. It is considered an option only for women who do not want to have children, when quality of life is significantly impaired and when all other treatments have failed. Hysterectomy might not cure the symptoms or the disease.

For recurrent severe endometriosis associated with chronic pain that has not responded to medical treatments or conservative surgery(ies), a hysterectomy and bilateral salpingo-oophorectomy may be performed. This is the removal of the uterus and both ovaries and fallopian tubes. This causes a surgical menopause, much like treatment with a GnRHantagonist or agonist would. Menopausal hormone therapy, or MHT (formerly called hormone replacement therapy, or HRT) may be needed in this situation.

Sometimes the surgery required may include removal of parts of the bowel or bladder containing endometriosis. This complex surgery is usually performed by a specialist laparoscopic gynaecologist, who may be joined by a specialist bowel surgeon or urologist.

Menopausal hormone therapy (MHT) after hysterectomy

If your ovaries are removed through surgery, menopausal hormone therapy, or MHT (formerly called hormone replacement therapy, or HRT), will prevent or reduce the effects of early menopause. However, there may be a small risk you will have a persistence or recurrence of your endometriosis because of the small amounts of oestrogen taken or absorbed during the therapy. Sometimes combined MHT is prescribed immediately after surgery.

Sometimes it is recommended you wait three to six months after your hysterectomy before you begin MHT. This delay may lead to any remaining endometrial implants wasting away. However, symptoms may be so severe that treatment becomes necessary immediately after surgery.

If you have had a hysterectomy, ask your doctor to refer you to a specialist clinic or centre for early menopause management. One type of MHT, called Tibolone, may be suitable as it does not stimulate endometrial cells in the same way as standard MHT does.

Managing symptoms in teenagers

Endometriosis in teenagers can be challenging to diagnose. Pain before and during a period (dysmenorrhoea) is the most common symptom, but the majority of teenagers with period pain will not have endometriosis.

Added symptoms, such as pain between periods, or symptoms involving the bowel or bladder, are more common than in adult women. The majority of endometriosis in adolescents is mild (Stage I/II), but the appearance at laparoscopy can be subtle and different from that in adult women.

If surgery is recommended, it is good to see a gynaecologist with specialist skills in this age-group.

Two-thirds of women with endometriosis have symptoms before the age of 20. For teenagers, particularly those under 16 years of age, the specialist and/or doctor may manage symptoms with medications before a laparoscopy. Common medications used are NSAIDs (non-steroidal anti-inflammatory drugs) such as aspirin, ibuprofen and naproxen. The aim of the medications is to reduce pain.

Hormonal treatments such as combined oral contraceptives and progestogens can be used to stop any bleeding and suppress the growth of endometrial cells. Medical management of painful periods improves symptoms in more than 70% of young women. It is important to note that girls who are not sexually active can take the combined oral contraceptive pill to reduce their symptoms.

However, if pain persists beyond three months, if you are unable to take medications, or if you have visited a doctor or hospital for pain three or more times in a six-month period, a diagnosis of endometriosis is more likely, and a laparoscopy should be offered. If you are referred to a gynaecologist specialising in endometriosis, the laparoscopy will include removal of the endometriosis, not just the diagnosis.

As a 25-year-old, Alice has not only spent years managing endometriosis, she has also been managing the expectations of friends who might not always understand what it's like to have a chronic condition. Watch the video and find out what she does.


This web page is designed to be informative and educational. It is not intended to provide specific medical advice or replace advice from your health practitioner. The information above is based on current medical knowledge, evidence and practice as at May 2019.

References

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    Berlanda N, Somigliana E, Viganò P, Vercellini P. Safety of medical treatments for endometriosis. Expert Opin Drug Saf. 2016 Jan;15(1):21–30.
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    Muzii L, Di Tucci C, Achilli C, Di Donato V, Musella A, Palaia I et al. Continuous versus cyclic oral contraceptives after laparoscopic excision of ovarian endometriomas: a systematic review and metaanalysis. Am J of Obstet Gynecol. 2016 Feb;214(2):203–11.
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    Tafi E, Leone Roberti Maggiore U, Alessandri F, Bogliolo S, Gardella B, Vellone VG et al. Advances in pharmacotherapy for treating endometriosis. Expert Opin Pharmacother. 2015;16(16):2465–83.
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    Somigliana E, Vercellini P, Vigano P, Benaglia L, Busnelli A, Fedele L. Postoperative medical therapy after surgical treatment of endometriosis: from adjuvant therapy to tertiary prevention. J Minim Invasive Gynecol. 2014;21(3):328–34.
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    Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D'Hooghe T, De Bie B et al. ESHRE guidelines: management of women with endometriosis. Hum Reprod. 2014;29(3):400–12.
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    de Sanctis V, Matalliotakis M, Soliman AT, Elsefdy H, Di Maio S, Fiscina B. A focus on the distinctions and current evidence of endometriosis in adolescents. Best Pract Res Clin Obstet Gynaecol. 2018;51:138–50.
Last updated: 28 September 2020 | Last reviewed: 15 May 2019

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