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Treatment of Endometriosis

Mar 27, 2015

The lining of the uterus is called the endometrium.  These are the cells that grow and bleed in response to our ovarian hormones to create the menses or period.  When those cells get outside of the uterus, they are called endometriosis.  They grow and bleed in response to the ovarian hormones the same way the lining of the uterus does but because the blood cannot escape, it causes irritation and inflammation.  When this is repeated month after month pain and scarring can occur.  There is no cure for endometriosis other than removing the ovaries.  However, removing the ovaries also causes menopause so this is clearly not the treatment for everyone. Endometriosis can be managed with medications or surgery.

Some women have endometriosis found incidentally when they are having surgery for something else.  If you have endometriosis but have no symptoms, you probably do not need to have any treatment at all.   Symptoms of endometriosis include pain and infertility.  If the pain is mild and only lasts for a short time, you have the option of just taking pain medications during those times.  Medications like ibuprofen or naproxen work the best and work best if taken in higher doses and prior to the onset of pain.

Many women want to know what natural or alternative treatments are helpful.  While alternative treatments have not been documented to decrease the actual amount of endometriosis present, they may help decrease both the intensity and the number of days of pain.

Daily exercise helps to relieve pain due to the menstrual cycle.  Exercise will also help decrease body fat.  Fat cells store estrogen, the hormone that stimulates endometriosis so maintaining a healthy body weight is helpful.  Some studies suggest that women who eat less red meat have fewer symptoms from endometriosis.  There are no studies about hormones in our food, but eating meat and dairy products that were not treated with hormones may be helpful.  Acupuncture has been shown to decrease pelvic pain no matter what the cause.  The acupuncture provider may also suggest herbal remedies that can help regulate the hormone cycle and decrease pain.

Medical treatments for endometriosis are hormonal treatments that cause suppression of ovarian function and/or suppression of the growth of the endometrial cells.  If you have endometriosis and are trying to get pregnant, medical treatment is not for you.  Since pregnancy and breast feeding both suppress endometriosis, if you want to get pregnant, you should go ahead and try.  If you get pregnant, you know you will have good treatment of your endometriosis for at least nine months, longer if you choose to breastfeed.  If you are trying to get pregnant and cannot, then you have two options.  You can see a fertility doctor (reproductive endocrinologist) to undergo in vitro fertilization (IVF).  Or you can have laparoscopic surgery to remove any endometriosis and inspect your ovaries and fallopian tubes.  Any adhesions (the medical word for scarring) that might be blocking the tubes can also be removed (lysed) at surgery.  

How can you decide which way to go?  The studies and data do not support one choice over another.  You can find studies that say the best way to get pregnant is to go straight to IVF.  But you can find an equal number of studies that suggest that the presence alone of endometriosis can decrease the success rate of IVF and that you should have surgery first, followed by IVF if the surgery alone does not result in pregnancy.  Your doctor can help you but the final decision will but up to you.  A review of your history, a physical exam and review of your insurance benefits will be necessary to make the decision.  IVF can be very expensive, so insurance coverage (or the lack there of) and your financial situation may push the decision one way or another.

If you are not trying to get pregnant, you have the choice of medical treatment or surgery.  Many medical treatments are extremely successful in treating the pain associated with endometriosis.  However, if you choose medical management alone, you need to be prepared to give any method you choose at least three or four months to start working.  

Birth control pills suppress ovarian function and also suppress the endometriosis directly.  Taking the pill gives you excellent contraceptive protection.  Taking the pill generally makes your periods very regular, lighter and less painful.  There are many brands and types of birth control pills.  Almost all of them will help.  You should talk with your doctor about which pill  might be the best for you.  The birth control patch (Ortho Evra) and the birth control ring (Nuvaring) work just as well as the pill without having to remember to take a pill every day.  With any of these methods, you should be prepared to have some irregular bleeding during the first two to three months.  Your period should become regular and light by the third or fourth pack.  If you are being treated with active pills daily, the aim is to not have any period at all after the first three months or so.  When you are ready to get pregnant, you can stop the pill and start trying right away.

Depo-Provera is also an excellent treatment for endometriosis.  This is an injection that is given every three months.  It also works by suppressing ovarian function and suppressing the endometriosis directly.  Most women will eventually not bleed at all on the Depo-Provera.  As with the pill, you should be prepared for irregular bleeding at the beginning.  With the Depo-Provera, the irregular bleeding may continue for the first three to six months.  Depo-Provera is excellent long term treatment for endometriosis.  However, the contraceptive effects can last for a year or longer after you stop using it so if you are older and will want to get pregnant sooner, you might want consider another option.

Mirena IUD (intra-uterine device) has also been approved by the FDA to treat endometriosis.  For women who do not want to have systemic hormone treatment, this is a great option.  The Mirena is inserted into the uterus by your gynecologist.  It provides local progesterone treatment to directly suppress endometriosis and prevent pregnancy.  It is even more effective than the pill at preventing pregnancy.  It does not suppress your ovarian hormones, so if you also have physical or emotional manifestations of PMS (premenstrual syndrome), you might be better of choosing the pill, the patch, the ring or Depo-Provera.  The Mirena should be effective for between five and seven years.  Like the pill, the contraceptive effects are immediately reversible.  When you are ready to get pregnant, you can have your doctor remove the IUD and start trying to get pregnant when you have your first period after removal.

 

The most powerful hormonal suppressant is Lupron.  Lupron is a monthly injection that induces a temporary menopausal state while you are on it.  It does a great job of suppressing endometriosis.  The usual course of treatment is six to twelve months.  After that, you should consider a longer term medical treatment (like those above) if you are not planning on getting pregnant.  The most common side effects are those of menopause, specifically, hot flashes.  Some women will feel irritable, gain weight or have joint pains.  Many women are happy regardless, because their pain has been relieved.  Like the other hormonal methods, Lupron can take three or four months to work.  If you are going to use Lupron, you should be prepared for a worsening of symptoms during the first month since Lupron stimulates your hormones the first month before it suppresses them.

If pain is controlled with medical treatments, some women might choose to avoid surgery altogether.  However, sometimes, surgery is the best option.  The only way to know for sure if you have endometriosis is to have surgery and take biopsies.  If you have never had surgery and it is not clear what is causing the pain or the infertility, surgery may be the best option in order to make a definitive diagnosis.  If medical treatment has not worked for you or you are trying to get pregnant, surgery may be the best option.  If the endometriosis is severe or if you are having pain with intercourse due to scarring in the pelvis, surgery may be the best option for you.  If you have had relief of your pain with surgery in the past, you may choose surgery as the best option again.  If you are going to have surgery, you should make sure that your surgeon is an experienced laparoscopic surgeon and is expert at removing endometriosis.  

Meet with an expert in endometriosis.  Make sure he or she understands your symptoms and has performed a thorough exam.  Your doctor can help you choose the best option (or combination of options) for you.

For more information: endometriosis.org