Lifestyle changes

The first step to easing the symptoms of endometriosis is maintaining a healthy lifestyle. Changes to your exercise and relaxation routines, and maintaining a balanced diet to stay healthy, may help help you manage the symptoms of endometriosis. Indeed, you may have found that eating certain foods may worsen your symptoms; keeping track might help you avoid those foods and thus relieve potentially debilitating attacks. Many women who suffer with chronic pelvic pain have found relief through regular exercise, such as yoga, employing mindfulness techniques and practicing meditation. These and other kinds of relaxation techniques may prove helpful in managing your symptoms. Make sure you get enough fluids and fibre to keep your bowels regular and to avoid constipation.

Medications

Hormone-based therapies can be used to manage endometriosis related symptoms, and may involve combined hormonal contraception, progesterone-like medications, or gonadotropin releasing hormone (GnRH) agonists with ‘add-back’ therapy (low doses of estrogen and progestin). Most often trying these medications for 2 to 3 months is advised to see if it helps with relieving pain symptoms.

Reducing estrogen levels may help manage pain related to endometriosis. Gonadotropin releasing hormone (GnRH) receptor antagonists (blockers) are a new type of medication that can reduce estrogen levels a little or almost completely depending on the dose. It’s reversible which means that the hormone levels go back to normal once the medication leaves the body.

Combined hormonal contraception

Combined hormonal contraception (such as the “pill”, the “patch” or the “ring”) is one of the most widely-used treatments for endometriosis. These contraceptives combine estrogen and progestin. This therapy reduces the pain caused by endometriosis.

Continuous combined hormonal contraception

Your health care provider might prescribe combined hormonal contraception without the usual seven-day break each month. This method prevents you from menstruating, and may be a useful option for women who experience their worst endometriosis symptoms during their period.  After you have been on combined hormonal contraception for at least three months, you may want to follow up with your health care provider to discuss how you are adjusting to the treatment and whether your symptoms are improving.

Progestin therapy

Progestin therapy is a class of medicine that has been used for birth control and has also been studied for the relief of endometriosis pain. It can be administered in a pill form or as an injection. Progestin therapy helps to lessen the effects of the estrogen that stimulates endometriotic growth in your body. As well, all progestin therapies may be associated with break-though bleeding. Break-through bleeding may be especially prolonged and heavy with progestin injections and could continue to be a problem until the effects of the injection wear off.

Common progestin therapy drugs include:

• Dienogest (this oral therapy is available in Canada)
• Norethindrone acetate (this oral therapy is available in Canada)
• DMPA (depot medroxyprogesterone acetate; this injection-based drug is available in Canada)

Dienogest is a class of medication that has been commonly used for birth control and more recently found to be particularly effective in the treatment of endometriosis, with few side effects. Your physician may prescribe this medication, a one per day oral tablet. This dosage may not be effective as a contraception, so a barrier method of birth control is advisable. Break-through bleeding may be a side effect.

Progestin IUD

If combined hormonal contraception or progestin therapy isn’t effective in treating your symptoms, your health care provider may recommend trying an intrauterine device (IUD). This is a common method of birth control, consisting of a T-shaped device which is inserted into your uterus. The device releases levonorgestrel, a type of progestin which counteracts the effects of estrogen in the same way that other progestin therapies do. The IUD can provide continuous therapy for five years or until it is removed by a health care provider. This may be an effective therapy for lessening your pain caused by endometriosis. The IUD is a very effective therapy because it stops menstruation and thus, slows down the growth of endometriosis.

GnRH agonists with ‘add-back’ therapy

Your health care provider may recommend a GnRH agonist (or gonadotropin releasing hormone agonist). This hormone, given by injection or nasal spray, will cause you to stop menstruating.  The side effects of this type of medication tend to be similar to symptoms you might experience in menopause: loss of bone mineral density, hot flashes, mood swings, vaginal dryness, smaller breasts and headaches. These symptoms can be relieved with add-back therapy, which is routinely given when a GnRH agonist is prescribed.

Add-back therapy

If you are taking a GnRH agonist, your health care provider may also prescribe a low dose of estrogen and progestin, or a progestin alone (such as norethindrone) (add-back therapy) to help deal with the menopause-like side-effects, while maintaining the pain relief. This will offset side effects such as hot flashes, vaginal dryness and even bone loss when GnRH agonists are used long term. The key principle is to use low doses of hormone replacement therapy, and if the patient has a uterus, to use combination estrogen/progestin therapy on a continuous basis. In women who have had a hysterectomy, low doses of estrogen alone may also be used.

GnRH antagonists

Your health care provider may recommend an oral gonadotropin releasing hormone (GnRH) receptor antagonist (elagolix) to treat the painful symptoms you may be experiencing caused by your endometriosis. This medication works by reducing the level of estrogen in your body partially or almost completely depending on the dose. Each individuals plan will be unique to their needs and symptoms.

The most common side effects of this type of medication are: hot flashes, headaches and nausea. It can also cause loss of bone mineral density (at the higher doses) and changes in mood. The effects and side effects are based on the dose given (once a day or twice a day).

Danazol

In the past, danazol was one of the most common medical treatments for endometriosis. It is a hormone that is taken orally and which causes you to stop menstruating. Although often effective in relieving the pain of endometriosis, danazol may be associated with many side effects including weight gain, acne, excessive hair growth, raised cholesterol levels, breast atrophy and (rarely) virilization. For this reason, danazol is rarely used for long-term treatment of endometriosis.

Cannabis

Since cannabis was legalized in Canada, more women are using cannabis products to help treat their endometriosis symptoms. While some women’s experiences suggest that cannabis might help manage pain and reduce the need for prescribed drugs, there is currently not enough evidence to make conclusions about the benefits and risks of cannabis use in the treatment of endometriosis. If you are currently using or thinking about using cannabis to manage your symptoms, speak to your health care provider to understand the potential risks and discuss available alternatives.

Pain relief

The therapies used to treat endometriosis may take at least one menstrual cycle to become effective. For this reason, your health care provider may recommend pain relief medication for use until the long-term treatment begins to work. Over-the-counter pain relievers known as non-steroidal anti-inflammatory drugs (NSAIDs) are often effective in treating the pain caused by endometriosis. These medications are inexpensive and non-addictive.

If you have tried an NSAID such as ibuprofen (Advil or Motrin) or naproxen (Aleve) and didn’t get much pain relief, you may want to try again. The most important thing to remember is that, unlike other pain medications, NSAIDs do not block existing pain. Instead, they block the production of prostaglandins, which produce the pain. You must start taking the medication before you expect the pain to start — before the prostaglandins are produced — and you must keep on taking it every six hours around the clock to ensure it works effectively.

For some patients, long-term use of NSAIDs may result in side effects such as stomach ulcers and bleeding. Let your doctor know when you are taking any over-the-counter medication.

Women with endometriosis are at a higher risk of long-term opioid use. One study showed that women with endometriosis are more likely than women without endometriosis to fill a prescription for opioids and to take higher doses for longer periods. Because of the dangerous and addictive nature of opioids, if you are taking opioids for endometriosis pain it is important to speak to your health care provider about alternative pain relief options, or to ask for help in managing your opioid use.

Surgical options

Surgery may be recommended:

• If you have pelvic pain which does not improve with the medications usually used to treat endometriosis, or if you cannot take those medications
• If your endometriosis is very extensive, involving the bowel, bladder, ureters or pelvic nerves
• If you have, or are suspected to have, an ovarian endometrioma
• If your diagnosis is too uncertain to proceed with treatment
• If you are experiencing infertility

How is the endometriosis removed?

Several techniques can be used during surgery to remove endometriotic growths and scarring. Which methods your health care provider chooses will be based on how extensive your endometriosis is and where it is located. Ablation  is the removal of tissue by an erosive process such as scraping or burning. Excision is the removal of tissue by cutting. Both can be effective in treating endometriosis, although excision is preferred for deeply invasive disease or endometriosis involving other organs. It is important to know that not all women experience improvement after surgery, and for some women endometriosis may eventually return. There are two types of surgery that can be effective in treating endometriosis: conservative therapy and definitive surgery (usually removal of the ovaries).

Conservative surgery

Laparoscopy is a surgery in which the surgeon can see inside of the abdomen through a tiny, lighted tube that is inserted through one or more incisions in your abdomen. It is the most common type of conservative surgery used to treat endometriosis. The goal of laparoscopy is to restore normal anatomy and relieve pain. This is often a good option for women of reproductive age who wish to conceive in the future or who do not want to undergo definitive surgery. Laparoscopy can be used to remove endometriotic growth or scarring and interrupt the nerve pathways that transmit pain. If you are having trouble getting pregnant, removal of endometriotic growth or scarring may help you to conceive. After surgery, your health care provider may recommend that you take medication to lower the chances of your endometriosis returning and to better manage the symptoms of endometriosis.

Definitive surgery

Definitive surgery involves the removal of the ovaries (causing menopause), and may also include removal of the uterus and Fallopian tubes. As well, all visible endometriotic growth is usually removed during this type of surgery. If you have significant pain and symptoms despite trying other types of treatment, and you do not want to become pregnant in the future, this may be an effective treatment for you. This type of surgery provides final relief from endometriosis-related pain in more than 90 per cent of women. May be recommended for women as a final treatment for their symptoms, it is generally recommended that both ovaries and all visible endometriosis be removed. If one or both ovaries are preserved, there is a chance that symptoms will come back, and additional surgery might be required. Many cases of definitive surgery can be done through laparoscopy, which offers quicker recovery and less pain than laparotomy.

Alternative treatments

Many women with endometriosis report that nutritional and complementary therapies such as acupuncture, traditional Chinese medicine, following a macrobiotic diet, herbal treatments and homeopathy improve pain symptoms. There is no evidence from randomized control trials to support these treatments for endometriosis, but you shouldn’t necessarily rule them out if you think they are beneficial to your overall pain management and quality of life. These kinds of therapies may be helpful to you in conjunction with other therapies. Speak with your health care provider if you are considering incorporating alternative treatments into your lifestyle.