How is endometriosis treated?

Treatment for endometriosis includes management of symptoms, surgical diagnosis, surgical removal of disease, and identification and management of additional conditions that cause pelvic symptoms. 

The decision to have and the timing of surgery will vary. An individual may not want surgery or may have medical conditions that prevent them from having surgery (this is uncommon). An individual may wish to or need to delay surgery for a variety of personal, financial, or medical reasons. (see “Tips for Dealing with Insurance“)

Surgery is needed for a definitive diagnosis. A “working diagnosis” may be made and treatment options discussed based on that. However, many treatment options may not stop the progression of endometriosis, and some surgical options may not address endometriosis in certain places (such as around bowel, ureters, or diaphragm). It is important, if an individual does not have endometriosis surgically addressed, that they are followed closely. Endometriosis in certain areas (such as close to ureters) can present further complications that may not present symptomatically- damage can be done without a change noticed in symptoms. Ideally, follow up and treatment would be someone with expertise in endometriosis. 

Treatment to eradicate (completely remove) the disease:

• Complete excision of abnormal tissue is the Gold Standard treatment and seeks to completely remove endometriosis (most often permanently) by surgically cutting out all of the disease at its roots.
• This method seeks to restore normal anatomy and preserve organs when possible.
• Recurrence rates are low when this procedure is done by surgeons skilled in identifying all forms of endometriosis and removal of endometriosis wherever it is found.
• It is important to identity and treat other causes of pelvic pain to have the best reduction/elimination of pelvic pain

Medical treatment – treats symptoms, but does not remove disease and can have significant long-term side effects. Medical therapy is an important part of endometriosis care, particularly for those whom surgery is not currently an option or have other ongoing problems or related conditions.

• Medication to treat pain such as non-steroidal anti-inflammatory drugs (see “Inflammation with Endometriosis“)
• Hormonal birth control medications often given continuously to stop menstruation include: combined birth control pills, progestin only birth control pills, progesterone containing intrauterine device (Mirena® IUD), injectable progesterone (Depo-Provera®), implanted progesterone (Nexplanon®) 
• Hormonal medications to induce menopausal state include: GnRH agonist/antagonists (Orilissa®, Lupron®, Synarel®, Zoladex®), androgens (Danazol®)

Surgical treatments that do not eradicate disease

• Ablation surgery is common. This is a surgical technique that attempts to destroy (“burns”) the surface of endometriosis lesions. However, it can often leave disease behind under the ablated areas, and it also does not allow for tissue to be confirmed by a pathologist. 
• Incomplete excision surgery 

Additional therapies can help manage symptoms, treat common conditions that contribute to pelvic pain, provide emotional support and reduce stress:

• Physical therapy 
• Diet/nutrition 
• Pain management 
• Mental health therapy

What skills does my doctor and their team need to diagnose and treat endometriosis? 

Endometriosis care requires holistic, multidisciplinary care. Who do you need on your team?

• Primary care providers and generalist ob/gyn providers need to recognize symptoms, understand the skill set needed for specialty care so that they can make the appropriate referral. Your primary care provider or ob/gyn providers may also be able to provide you with some medications to manage your symptoms until you can see a specialist. Most generalist ob/gyn providers do not perform enough surgery on endometriosis patients to have the skill level of surgeons who specialize and treat primarily endometriosis. (see “Managing Your Relationship With Your Current Doctor“)
• Surgeon – Identification of endometriosis and complete excision of disease requires a surgeon does a large volume of endometriosis surgery. Endometriosis lesions come in many shapes, colors, sizes and can present in numerous places in the body. Endometriosis, particularly deep infiltrating endometriosis (DIE), required a very high level of surgical skill. Endometriosis in some locations requires that an endometriosis surgeon partner with another specialized surgeon to remove lesions on the bowel, lung, sciatic nerve, or other locations. (see “Choosing Your Surgeon“)
• Other specialists: Physical therapy, Nutritionist, Pain Management, Mental Health Therapist, and Others