Endometriosis affects an estimated one in 10 women around the world and can cause infertility, severe pain that disrupts school or work, and pain with urination, bowel movements, or sex.
Women who have been diagnosed with endometriosis—when tissue that lines the inside of the uterus grows elsewhere—have several potential treatments to consider. But because many of them are short-term treatments, they may try several of them throughout their lifetime.
No matter which endometriosis treatment you choose first, you might be best off assembling a team of people to help tackle the condition, says Sanjay Agarwal, MD, director of the Center for Endometriosis Research and Treatment at the University of California, San Diego. There, he’s brought together nutritionists, pain specialists, psychologists, and even acupuncturists to help women address endometriosis from every possible angle they can.
“Endometriosis is a complex disease, and no one of us has all the skills necessary to comprehensively take care of women with endometriosis,” Dr. Agarwal tells Health.
Some women with extremely mild cases may be able to manage their endometriosis pain with a natural treatment like adopting an anti-inflammatory diet, which involves learning to avoid foods that may worsen their symptoms. They might also find success with alternative or complementary treatments, like acupuncture, mindfulness, and psychological therapy.
But women with moderate or severe pain have a different set of treatment options to consider. Depending on the severity of their pain, and the way it impacts their daily life, they may want to consider a range of medications and surgical procedures.
Dr. Agarwal ranked these broad categories of endometriosis treatment from least to most invasive.
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Birth control
In some cases, endometriosis is so mild that a simple birth control pill might bring relief. In fact, a prescription for the pill may be the first thing a physician suggests to a patient, Dr. Agarwal says.
Because endometriosis is driven by estrogen levels, the birth control pill controls the disease by keeping hormones stable.
There aren’t any high-quality studies demonstrating how many women find relief from endometriosis symptoms with the pill, but the medication itself is cheap, relatively safe with few side effects, and may help a small percentage of women, Dr. Agarwal says.
This may be why organizations like the American College of Obstetricians and Gynecologists (ACOG) and the American Society for Reproductive Medicine (ASRM) recommend birth control pills as a first-line treatment for endometriosis pain that can’t be controlled with over-the-counter pain relief drugs like Motrin or Advil.
Other contraceptive options include the birth control shot, which helps with pain by suppressing ovulation and thinning endometrial lining. However, compared to the birth control pill, some women might find that it causes more mood trouble, weight gain, and irregular spotting, Dr. Agarwal says.
“There aren’t fabulous studies assessing birth control pills, but they do seem to work for a reasonable proportion of women,” he says. “If they don’t work, then we should use more aggressive medicines, and they should consider surgery.”
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Gonadotropin-releasing hormone antagonists and agonists
If birth control pills don’t work, women can continue exploring more intense or invasive endometriosis treatments to try to decrease their pain.
Orilissa, the first new endometriosis drug to win FDA approval in more than 10 years, is a pill that comes in two different doses to treat moderate or severe pain. It’s a gonadotropin-releasing hormone (GnRH) antagonist, which means that it binds with hormone receptors to reduce the body’s production of estrogen and progesterone. This, in turn, reduces the pain.
The drug’s most common side effects are things like hot flashes, headaches, and insomnia. But Orilissa can also have some serious side effects for a minority of women, including loss of bone density and a higher incidence of suicidal thoughts and behaviors, especially in women who have a history of depression.
But Dr. Agarwal is encouraged by its approval because it comes in two different doses and because of how it’s delivered. “It’s a pill, so if you don’t like it, you can stop it easily,” he says.
Then there are FDA-approved GnRH agonists for endometriosis, which work by telling the pituitary gland to stop producing a hormone that stimulates estrogen production in the ovaries. The most well-known example for endometriosis is Lupron, which is administered via injection. These shots suppress estrogen to stop endometrial lesions from forming but can cause similar side effects to Orilissa.
To mitigate those side effects, women may also be instructed to “add back” a small amount of those blocked hormones in the form of a daily progesterone or estrogen pill.
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Androgen medication
Danazol (its generic name) was the first drug to be approved by the FDA for endometriosis. It was widely used when it was first introduced in the 1970s, but the drug has since fallen out of favor in most of the Western world.
This is because the medication works by introducing higher levels of male hormones, or androgens, in the body, in an effort to bring down levels of estrogen. For many women, the side effects of this medication include increased body hair, a deeper voice, shrinking breasts, and acne.
“In this day and age, we don’t use danazol very often,” says Dr. Agarwal, who characterizes the drug as “quite invasive.”
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Opioids for chronic pain
Some women with endometriosis are prescribed opioids—strong, potentially addictive painkillers—to cope with either chronic pain or pain after a surgery for the condition.
But aside from a brief post-operative period, doctors are now becoming more wary of prescribing opioids to patients long-term, no matter what the condition. In 2017, an estimated 1.7 million Americans had substance use disorders linked to prescription opioids, while 47,000 died of opioid overdose, according to the National Institute of Drug Abuse.
Experts say that the best way to reduce dependency on opioids is to never start on them in the first place, which is why doctors are beginning to reduce their opioid prescriptions.
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Surgical treatment
For some women, medicine may not help bring relief from pain or cramping, even after trying several different kinds. Pharmaceuticals also can’t reverse the damage that has already been caused by untreated, long-term endometriosis, like adhesions or scarring.
And finally, while drugs are less invasive than surgery, they aren’t appropriate for women trying to conceive, says Hugh Taylor, MD, vice president of the ASRM and chair of obstetrics, gynecology, and reproductive science at Yale School of Medicine.
“I would recommend surgery for those who do not respond to a trial of at least two medications—don't give up if the first drug does not work,” says Dr. Taylor, who uses both medical therapy and surgery to help treat endometriosis in his patients. “Surgery is appropriate as ‘first line’ in someone who wants to become pregnant right away or who can't use medications.”
Generally, surgeons will perform a laparoscopy to surgically treat endometriosis. They make a small incision in the abdomen to insert a laparoscope, which is a long, thin tool that lights up the abdomen. From there, they insert other tools that will help them to remove endometrial implants that may line the abdominal walls or be on the surface of other organs.
They may also remove endometriomas, which are endometrial cysts on ovaries, and in some cases cut away adhesions, or scar tissue, that may have formed because of the condition. Finally, some women may decide to have organs like the ovary or the uterus removed.
Dr. Taylor advises women considering surgery to choose a surgeon who is also an endometriosis expert and who works as part of a multidisciplinary team. “The most comprehensive centers can work with experts from other specialties, such as gastrointestinal surgeons, when needed,” he says.
After surgery, women may get relief from pain or heavy bleeding, but the symptoms could come back without long-term medical treatment to prevent the endometriosis from recurring, Dr. Taylor says.
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Diagnosing endometriosis
While prominent figures in Hollywood and media are raising awareness of endometriosis, there are still too many women who live with pain for years before getting a formal diagnosis, Dr. Agarwal says.
Some research suggests that women may go anywhere from three to 11 years between the beginning of pain and an endometriosis diagnosis. This, in part, was because doctors at first waited to confirm a diagnosis with surgery. This is slowly changing, experts say, but more awareness about endometriosis and its symptoms is still needed among both doctors and the general public.
“Worsening menstrual cramps are often the first sign,” Dr. Taylor says. “If cramps are bad enough that you miss work or school, then it is almost always endometriosis.”
“We don’t always need surgery [to diagnose],” Dr. Agarwal adds. “Let’s get on with treatment.”
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