Treatment and Management

As a treatment for endometriosis, surgery can be used to alleviate pain by removing the endometriosis, dividing adhesions or removing cysts. There are three options of surgery for treating endometriosis; conservative surgery, complex surgery and radical surgery.

Conservative surgery aims to remove or destroy the deposits of endometriosis and is usually done via a laparoscopy (keyhole surgery). The surgeon can either cut out the endometriosis (known as excision) or destroy it using heat or laser. Although surgery can provide relief from symptoms, they can recur in time. 

Depending on the severity of your endometriosis, you may need to undergo more complex surgery that involves different organs within the body, such as the bowel or the bladder. These types of surgery will often include a multi-disciplinary team such as a colorectal surgeon, and are usually carried out via laparoscopy. Any complex surgery should be discussed thoroughly with your doctor or specialist.

More radical surgery can be considered if a patient has not responded to drug treatments or conservative surgery and is not planning to start a family. Radical surgery refers to a hysterectomy or oophorectomy.

Hysterectomy is the removal of the womb, and is performed under general anaesthetic. It can be done with or without removing the ovaries. If the ovaries are left in place then the chance of endometriosis returning is increased.  Some women need a further operation to remove the ovaries at a later date. Hysterectomy is not the right operation for everyone and not a decision to make lightly. Consider all options and discuss things fully with your GP or gynaecologist.  Remember that a hysterectomy is irreversible.

Oopherectomy is the removal of the ovaries. When both ovaries are removed, the surgical procedure is called “bilateral oopherectomy,” whereas the removal of only one ovary is called “unilateral oopherectomy.” When both ovaries are removed, a patient will experience an instant and irreversible menopause.

These procedures may be considered for a number of reasons. The decision to have either of these procedures is a big one to make – they are irreversible, so the advantages and disadvantages of each surgery should be discussed in full with your consultant.

As endometriosis responds and grows when exposed to the female hormone oestrogen, a number of hormone treatments attempt to block or reduce the production of oestrogen in the body. Treatments aim to relieve symptoms and to prevent endometriosis from growing.

If you are offered the choice of hormone treatment, you may want to discuss with your doctor what the treatment involves, the pros and cons, along with the possible side effects of the treatment.

Hormone treatments work by reducing levels of oestrogen in the body preventing the lining of the womb and any endometriosis tissue from growing quickly. Some treatments work by causing a medical menopause. All treatments are temporary and the effects are reversed when the patient stops taking the hormones. Please note that these drugs have no effect on adhesions neither do they help to improve fertility.

Your doctor will be able to discuss different hormone treatment options that are available to you.

The pill contains the synthetic female hormones oestrogen and progestogen. The combination of these hormones stops eggs being released (ovulation) and make periods lighter and less painful. When taking continuously, back-to-back, periods stop and the symptoms of endometriosis are reduced.

The pill is commonly used to treat endometriosis before a definite diagnosis, as most people who take it do not suffer from side effects. It can also be taken safely for many years. The pill can be taken continuously (without a monthly break) to avoid bleeding.

An IUS is a small plastic T-shaped intrauterine device. It contains a progestogen (progesterone-like substance) that is released into the womb over a period of 5 years. This does not always stop ovulation.

The female sex hormone progesterone stops the endometrium (womb lining) from growing. If the endometrium is exposed to progesterone for a prolonged amount of time it will become thin and inactive. Progesterone has the same effect on endometriosis.

Progestogens are synthetic progesterone hormones, which are used to recreate this effect on the endometrium and endometriosis. The dose of the drug is usually adjusted until periods stop.

There are different types of progestogens available, which may have different side effects. Some are also available in different forms:

• Desogestrel
• Levonorgestrel
• Etonogestrel
• Medroxyprogesterone acetate
• Norethisterone
• Dienogest

There are no known long-term side effects of progestogen treatment.

GnRH is hormone that we naturally produce, and GnRH analogues are a family of drugs that are chemically similar to this natural hormone. The growth of endometrium (lining of the womb) and endometriosis is dependent upon the action of hormones, including GnRH.

GnRH analogues stop the ovaries from being stimulated stopping the production of oestrogen. Therefore, the endometrium and endometriosis become inactive and do not grow.

A simple hot water bottle or hot bath may help to reduce pain. Some women also find heated wheat bags to be effective. Being comfortable and reducing stress will also be beneficial.

NSAIDs such as ibuprofen, naproxen, diclofenac and mefenamic acid block the production of prostaglandins in the body. Prostaglandins occur naturally, in response to injury or disease, and cause pain and inflammation.  They have a number of functions including making the womb contract during a period (which helps with the shedding of the womb lining). These contractions can cause pain. It is thought that women with endometriosis may produce more prostaglandins than women without the condition.

NSAIDs work more effectively if they are taken before the body produces prostaglandins. Many people take NSAIDs as they would other painkillers such as paracetamol. It is best to start taking NSAIDs the day before, or several days before, a period or pain is expected. Common side effects of NSAIDs include nausea, vomiting, diarrhoea, stomach upsets and stomach ulcers. These side effects can be reduced by taking NSAIDs with food or milk. A medication may also be recommended to take alongside NSAIDS to protect the stomach, these are called proton-pump inhibitors.

Codeine-based painkillers are effective painkillers but can cause constipation and gastro-intestinal upset, which may aggravate symptoms in women with endometriosis.

Simple analgesics such as paracetamol can be used to treat mild pain.         

Physiotherapists can develop a programme of exercise and relaxation techniques designed to help strengthen pelvic floor muscles, reduce pain, and manage stress and anxiety. After surgery, rehabilitation in the form of gentle exercises, yoga, or Pilates can help the body get back into shape by strengthening compromised abdominal and back muscles.

These drugs work by altering the body’s perception of pain. Tricyclic anti-depressants (example – Amitriptyline) are drugs that are mainly used to treat depression but have been found to have an effect on the nervous system and the way the body manages pain.  The pain messages travel through the body’s central nervous system, but these drugs can help to stop those messages from reaching the brain.

TENS machines are an alternative to pain killers.  They are small, unobtrusive machines with electrodes that attach to the skin and send electrical pulses into the body. This does not hurt but instead feels mildly ticklish. The electrical pulses are thought to work by either blocking the pain messages as they travel through the nerves or by helping the body produce endorphins which are natural pain-fighters. Some TENS machines can be clipped to a belt. Check with your GP before using a TENS machine as they are not suitable for those who may be pregnant or who have a heart condition.

Some hospitals and trusts have specialised pain clinics providing advice and support to people in chronic pain. Ask your GP about a referral to your nearest pain clinic.