Endometriosis treatment
Endometriosis is a chronic condition. There is currently no cure for it, but there are both medical and surgical treatment methods that can help reduce your symptoms and manage any potential complications.
Medical treatment
The primary goal of medical treatment is to halt the growth and activity of the endometriosis. There are several options available to achieve this. The most common ones are oral contraceptive pills, hormonal IUDs (intrauterine devices), and GnRH analogues. All of these treatment methods aim to suppress menstruation and reduce the levels of hormones that are needed for the endometriosis to grow (the most important one being estrogen). The effects vary from person to person, so you may have to try different ones before finding a method that works for you. In some cases, a combination of two or more treatments may be necessary.
Oral contraceptive pills
Oral contraceptive pills are usually the first option. There are two different types: the combined pill (which contains both estrogen and progestin) and the progestin-only, also known as the "mini pill" (which only contains progestin). When used to treat endometriosis, hormonal pills are most effective when taken continuously so as to avoid breakthrough bleeding.
The most common side effects are mood changes, depression, weight gain, bloating, nausea, headaches, and breast tenderness. Each type of pill can affect each woman differently. Some may cause more side effects than others, so don't give up if the first one you try doesn't work.
Combined contraceptive pills increase the risk of certain conditions, e.g. blood clots, heart attacks, and stroke. This risk is even higher in women who already have (or have had) any of these conditions or migraine with aura. These women should avoid combined pills altogether and try progestin-only contraceptive pills instead.
Hormonal IUDs
Hormonal IUDs (e.g. Mirena) are small, often T-shaped birth control devices that are inserted into a woman's uterus. Once inserted, the effect lasts for approximately 5 years. IUDs deliver a lower dose of hormones than contraceptive pills. Mirena, for example, releases 20 micrograms of levonorgestrel (similar to progesterone) per day. IUDs don't stop ovulation and hormone production completely, and don't always suppress menstruation (although they do reduce it).
The hormonal effects of IUDs are mainly local, meaning that they only affect the uterine cavity, and not the entire body. For this reason, IUDs have very few systemic side effects. It is common to feel discomfort or pain during and immediately after the insertion. Some women also experience cramping for the first 1-2 weeks. It can be good to know that women with endometriosis usually experience more pain, both during and after the insertion.
Although it is very rare, IUDs can sometimes perforate the wall of the uterus, which can damage the internal organs. In these cases, surgery may be required to remove the IUD. If pregnancy occurs (which is also very uncommon), there is an increased risk of serious complications such as ectopic pregnancy, infection, early delivery and miscarriage. The IUD may also imbed itself in the placenta or injure the fetus.
GnRH analogues
GnRH analogues (or agonists) are drugs that block the effect of a hormone called gonadotropin-releasing hormone (or GnRH). GnRH controls the secretion of LH and FSH, two "sex hormones" that stimulate follicular growth and ovulation in women. Blocking GnRH leads to the suppression of LH and FSH which prevents ovulation and menstruation - the same way as menopause does. Unlike menopause, however, the effect is reversible.
GnRH agonist therapy is a powerful and effective treatment that results in symptomatic relief in up to 90 % of patients with endometriosis (Mohamed A. Bedaiwy, Tommaso Falcone, in General Gynecology, 2007). However, they have a lot of short-term and long-term side effects. The most common short-term ones include mood swings, depression, irritability, hot flashes, increased sweating, headaches, dizziness, tiredness, trouble sleeping, vaginal dryness, and muscle and bone pain. Some of these can be avoided by taking a very small dose of estrogen daily (called "add-back therapy").
One of the main long-term problems is that GnRH agonists reduce our bone mineral density, which increases the risk of developing osteoporosis, even with add-back therapy. For this reason, it is not recommended to use these drugs for more than 6 months at a time. While some studies have found that the bone mineral density is back to normal 1-2 years after cessation of the treatment, others believe it takes longer. Another problem is the treatment's effect on fertility. The production/release of sex hormones goes back to normal when you stop taking the drugs, but it is unclear how long it takes.
GnRH analogues are usually administered either as subcutaneous injections or as a nasal spray. They are often sold under the brand names Lupron, Zoladex and Synarel in the US, and Enanton and Synarela in Sweden.
Surgical treatment
The goal with surgical treatment is to remove or destroy the endometriosis without causing additional harm (e.g. scar tissue, adhesions, or damage to organs or blood vessels). It can improve fertility and alleviate symptoms, but it doesn't cure endometriosis.
Most surgery is performed with laparoscopy, also known as "key-hole surgery". Laparoscopy is easier than open surgery and leads to less postoperative pain and a faster recovery. The surgeon makes a few small incisions and removes visible endometriosis with the help of a camera, either by ablation ( destroying the lesions, usually by burning) or excision (removing by cutting it out with scissors). Ablation is quicker and easier (and cheaper), and there are more surgeons who know how to do it. It also stops the bleeding quicker and the wounds heal faster. However, it leaves more scar tissue, has higher recurrence rates, and it's harder to remove the entire lesions using ablation. This is why excision is usually recommended, at least for deep endometriotic lesions.
Surgical treatment requires skilled and experienced endometriosis surgeons, especially when the patient has very small and superficial lesions that are easy to miss. Many surgeons use the term "invisible microscopic endometriosis" (IVE) to describe endometriotic tissue that they believe is too small to be seen with the magnification of a laparoscope. However, most experienced surgeons believe that there is no such thing as IVE, and that virtually all of the endometriosis is visible as long as you are experienced enough and know where to look.
What about getting a hysterectomy?
It is a common misconception that a hysterectomy will cure endometriosis. While it does alleviate symptoms in many cases, it is not the miracle treatment that a lot of people seem to believe.
There are several different kinds of hysterectomies:
- Total hysterectomy = removal of the entire uterus
- Subtotal hysterectomy = removal of most of the uterus, except for the cervix
- Radical hysterectomy = removal of the uterus, cervix, both ovaries and fallopian tubes, and the upper part of the vagina
- Salpingooforectomy (SOE) = removal of the ovaries and fallopian tubes
If you only remove the uterus but leave one or both ovaries, the endometriosis can keep growing since the estrogen production in the ovaries continues. You will probably have to continue with some kind of hormone therapy since the endometriosis will continue to grow and cause pain. However, removing the uterus can help if you have adenomyosis, and it also stops your menstruation. All in all, this is not recommended as a treatment for endometriosis in Sweden.
A radical hysterectomy is more likely to alleviate your pain since the surgeon removes the ovaries as well, thus stopping their estrogen production. However, it is impossible to know how much it will help in advance. A radical hysterectomy can be performed after you are done having children and if you have tried several hormonal treatments with poor results.
Studies have shown that hysterectomies performed in women with endometriosis have a higher risk for complications than when performed for other reasons. Before surgery, the patient needs to be well-informed about the advantages and disadvantages of the hysterectomy, any potential complications that may occur, and what results they can expect. Endometriosis surgery can be very complicated and requires an experienced surgical team.