Treating endometriosis

Endometriosis can be treated medically (with drugs or medicine) or with surgery. Sometimes both medicine and surgery are used. Some women also benefit from alternative therapies.

On this page:

• Treatment to improve fertility
• Treatment for pain
• Alternative and complementary therapies
• Choosing not to treat endometriosis
• Benefits and disadvantages of different treatments 

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Medications range from pain relief drugs (such as paracetamol and anti-inflammatories), to hormonal treatments that suppress ovulation and periods.

Surgery can be used to remove or destroy the endometriosis. The most common surgery approach is laparoscopy (key-hole surgery).

Cysts of endometriosis on the ovaries (endometriomas), are unlikely to disappear on their own and generally cannot be treated with medicine. They may be removed surgically if they are causing symptoms or they are large. Small endometriomas that are not causing symptoms may be observed with regular ultrasounds.

Treatment to improve fertility

Surgery has been shown to improve fertility for women with mild endometriosis. Treating more severe endometriosis with surgery, especially if there are cysts in the ovaries, might also improve fertility, but this hasn't been proven. If the fallopian tubes are blocked and fluid-filled (hydrosalpinx), natural fertility is reduced. However, there is also a reduction in success rates with assisted reproductive technologies such as IVF if there is a hydrosalpinx present. If a hydrosalpinx is found, it is often recommended that the affected tube or tubes are removed at the time of surgery.

Other causes of infertility should be looked for and treated. Medication for endometriosis has not been shown to improve fertility.

Treatment for pain

When pain is the main problem, the treatment aims to relieve symptoms and lessen the pain. 

• Simple pain relievers (paracetamol, etc)
  Many women will experience some relief of symptoms with over-the-counter medications such as paracetamol (Panadol) and non-steroidal anti-inflammatories (Ponstan, Nurofen, Naprogesic, etc).

• Hormonal treatments (the Pill, etc)
  Hormone treatments are used to suppress the normal menstrual cycle, which in turn stops or slows endometriosis growth and in some women are effective in reducing endometriosis-related pain. Hormonal treatments are available in multiple types, including tablets (such as the combined oral contraceptive pill – ‘the pill’), intrauterine devices (the Mirena), implants or injections. Some women will experience side effects with hormonal treatments. Some medications aim to ‘turn-off’ the body’s natural hormone production to reduce the activity and growth of endometriosis. These medications induced a ‘menopause-like’ state, and a low-dose hormone replacement may be given at the same time to manage side-effects and long-term effects.

• Laparoscopy (keyhole surgery)
  Surgery may assist in diagnosis of endometriosis, especially for minimal or mild endometriosis where ultrasound scans may be normal. Surgical treatment often improves pain symptoms associated with endometriosis, and is offered in addition to hormonal treatments. Surgery for endometriosis involves a laparoscopy (key-hole surgery), where a small telescope is inserted into the abdomen to identify endometriosis, and other instruments are used to treat it. Treatment involves either excision (removal of the endometrial tissue using cutting), ablation (which involves destroying the endometriosis cells using diathermy) or a combination of both techniques. The choice of technique is made by the surgeon depending on the size and location of the lesion to be treated. If either technique is appropriate, excision is generally performed to allow the tissue to be sent for examination under the microscope to confirm the diagnosis.

• Hysterectomy
  In a small group of women who have severe symptoms that are not relieved by medical or other surgical treatment, more extensive surgery such as hysterectomy (removal of the uterus, cervix and fallopian tubes) with or without removal of the ovaries may be considered. This is usually performed with key-hole surgery, however the recovery is longer than for laparoscopy with treatment of endometriosis alone. Often this is treating other possible causes of pain coming from the uterus (such as adenomyosis), as well as removing the source of possible future regrowth of endometriosis

• Bowel surgery
  Sometimes endometriosis affects the wall of the bowel. When this is causing significant symptoms it may be suggested that the affected piece of bowel is removed. This surgery is performed in conjunction with a specialist colorectal (bowel) surgeon.

Alternative and complementary therapies

There are various treatments available that can either complement your medical treatment or are an alternative to medical treatment. The most popular is traditional Chinese medicine and herbal preparations. Some women experience improvement of their symptoms with these but there is no scientific evidence to support the effectiveness of Chinese medicines in reducing symptoms or improving fertility.

If you use complementary treatments it is wise to discuss their use with your doctor as they may interfere with other prescribed medications. The Pharmaceutical Benefits Scheme (PBS) does not cover the costs of alternative or complementary therapies.

Choosing not to treat endometriosis

Endometriosis doesn't always need treatment. Treatment of endometriosis is indicated to treat symptoms (including pain) or infertility, when your quality of life has suffered.

If left untreated, sometimes endometriosis symptoms will improve, but most will stay the same. Some people will find their symptoms become worse without treatment.

For most women with endometriosis, the symptoms will settle once they go through the menopause. Deciding whether or not to treat endometriosis is often a matter of balancing the risks of the treatment against the effect the endometriosis is having on your life.

Benefits and disadvantages of different treatments 

No treatment for endometriosis will guarantee an improvement in symptoms. Assessment of the severity of symptoms and the benefits and risks of the available may assist in determining the best option. Many women use multiple treatment options together and at different times in their life.

	Benefits	Disadvantages
Doing nothing – no treatment	No side effects of drugs No risks of surgery	Symptoms may remain unchanged or deteriorate
Simple pain relief (paracetamol, ibuprofen)	Easy to get and affordable Side effects are uncommon	Ibuprofen use has some health risks, including irritation of the lining of the stomach
Progesterone-only medications	Reduced pain Reduction or cessation of period bleeding Some are contraceptive Multiple modes of administration are available (oral, implant, intrauterine device, injection)	Possible side effects – weight gain, mood changes, acne, increased hair growth, cramps, breast tenderness, irregular period bleeding or spotting Symptoms may recur when treatment is stopped Doesn't improve fertility Not all options are contraceptive, and pregnancy should be avoided while taking hormonal treatments
The combined contraceptive pill	Contraceptive Reduced pain Can be taken to reduce or stop periods	Possible side effects – nausea, weight gain Shouldn't get pregnant while on it Small increase in risk of clots in legs or lungs Symptoms may recur when treatment is stopped
GnRH Analogues  (temporary menopause-inducing medications) – used with or without hormone replacement ‘add-back’ (HRT)	Periods stop while using the medication Very effective in reducing pain related to endometriosis Stops endometriosis growth in most cases	Side effects – hot flushes, sweats, vaginal dryness, mood changes. These may be managed with simultaneous use of HRT medication Bone thinning if used for more than six months Endometriosis symptoms may recur when treatment is stopped Not a contraceptive and pregnancy should be avoided while using the medication Only 6 months of treatment is subsidised by the PBS, and after this the medication becomes expensive
Laparoscopy	Provides a certain diagnosis of endometriosis A long-term cure in up to 70 percent of women Can improve symptoms in women who are unable to use medical treatments	Not all endometriosis can be treated this way Risks associated with surgery – pain, bleeding, infection, damage to bladder/bowel/ureter/ovary, scarring, blood clots in legs or lungs, needing to make a large cut on the abdomen, death Recurrent endometriosis with symptoms in 30 percent of women
Hysterectomy and removal of endometriosis	Achieves long-term cure in over 90 percent of women Reduces or eliminates need to use medications long-term No periods	Risks of surgery greater than laparoscopy with treatment of endometriosis alone Removes fertility Some women grieve for uterus loss May need hormone replacement therapy if the ovaries are removed May not cure pain

Research in endometriosis

The Royal Women’s Hospital and University of Melbourne have a large endometriosis research group. If you are a patient of the Women's you may be approached to participate in research into improving the diagnosis and treatment of endometriosis. Participation is voluntary. If you wish to learn more about the research being performed at the Women’s please see the links below.

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