Diagnosis and Treatment

Every woman experiences endometriosis differently. The signs and symptoms vary greatly from person to person, and may also be related to other conditions. For these reasons, the path you travel — from the onset of your symptoms and through diagnosis and treatment — will be unique, and sometimes challenging.

In this section, you will find information on the following:
The first step - Seeking help

Lifestyle changes - Simple solutions that may help ease your pain

Hormone-based therapy - Drug options for treating endometriosis

Pain relief - Easing the pain until medical therapy takes effect

Surgery - When medical therapy isn’t enough …

Alternative treatments - Complementary therapies to consider

 

The diagnosis and treatment options that are right for you will depend on a number of factors :

• Your age
• What symptoms you have and how they affect your quality of life
• Your desire to have children
• The location of your endometriosis and the extent of its growth

Although there is no cure for endometriosis, a variety of options exist that can improve your quality of life. These treatments focus on reducing the painful symptoms of this disease, and can also improve your chances of becoming pregnant. Treatments can shrink or slow the growth of endometriosis to preserve or restore fertility, and prevent or delay the return of the disease.

The treatment that is right for you may involve a combination of lifestyle changes, medication, surgery and alternative approaches, depending on what you and your health-care professional decide is best.

 

The first step

To begin the diagnosis and treatment process, your health-care professional will do a thorough medical evaluation, including collecting information about your symptoms and your gynaecologic health history. Talking with your doctor.

You might be asked about …

• Your pain and symptoms
• Your reproductive health (age of first period, menstrual cycle frequency and regularity, pregnancy history)
• Medications you are taking or have taken
• Your family history of endometriosis or gynaecologic cancers
• Your medical history
• Your general health

A physical examination is also necessary to make a diagnosis and decide on appropriate treatment. Your health-care professional will perform a pelvic examination, and possibly a rectal-vaginal examination. This enables him or her to feel for signs of endometriosis or other disorders that may be causing your symptoms.  Your doctor might perform this examination when you are menstruating, as scientific evidence suggests that this could improve the chances of detecting endometriosis.

Your health-care professional may also perform an ultrasound, which can detect ovarian cysts and other pelvic disorders that might be causing your symptoms. If the endometriosis is suspected to be very extensive, other non-invasive imaging tests such as a colonoscopy, cystoscopy, rectal ultrasound or MRI may be required.

In many cases, your health-care professional will recommend appropriate treatment based on the information collected from your medical history (the questions above), physical exams and imaging tests. For some women, further diagnostic tests (such as laparoscopy) might be necessary. However, laparoscopy is a surgical procedure and all surgery has some amount of risk, so it is not recommended for all women. Your health-care professional will usually recommend that other less invasive treatment options are tried first.

 

Lifestyle changes

If you are diagnosed with endometriosis, your health-care professional will discuss lifestyle changes with you. Changes to your exercise and relaxation routines, and maintaining a balanced diet to stay healthy, may help ease the symptoms of endometriosis.

 

Hormone-based therapy

Hormone-based therapies can be used to treat endometriosis, and may involve combined hormonal contraception, progesterone-based drugs, or GnRH agonists with 'add-back' therapy (low doses of estrogen and progestin).

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. This therapy reduces the pain caused by endometriosis by suppressing menstruation and inhibiting the growth of endometriosis.

Your health-care professional 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 professional to discuss how you are adjusting to the treatment and whether your symptoms are improving. 

Progestin therapy
Progestin therapy (such as “the shot”) is widely 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.

One drawback of injection-based progestin therapy is that there can be a delay between when therapy is stopped and when ovulation resumes. For this reason, this is not an effective option if you are planning to conceive in the near future. This therapy can be a good option for women with endometriosis who have had a hysterectomy, because future conception and irregular bleeding are not issues. 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.

 

 

Intrauterine system (IUS)
If combined hormonal contraception or progestin therapy isn’t effective in treating your symptoms, your health-care professional may recommend trying an intrauterine system (IUS).  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 IUS can provide continuous therapy for five years or until it is removed by a health-care professional. This may be an effective therapy for lessening your pain caused by endometriosis.

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.

GnRH agonists with ‘add-back’ therapy
If combined hormonal contraception or progestin therapy doesn’t work for you, your health-care professional 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.

 

Pain relief

The therapies used to treat endometriosis may take at least one menstrual cycle to become effective. For this reason, your health-care professional may recommend pain relief medication for use until the long-term treatment begins to work.

Over-the-counter anti-inflammatory medication (NSAIDs) is often effective in treating the pain caused by endometriosis. These medications are inexpensive and non-addictive.

However, 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.

 

Surgery

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 needs to be removed because of the way it is affecting your internal organs
• If your endometriosis is very extensive, involving the bowel, bladder, ureters
  or pelvic nerves
• If you have, or are suspected to have, an ovarian endometriomas
• If your diagnosis is too uncertain to proceed with treatment
• If you are experiencing infertility

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 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.

Laparotomy can also be used to achieve the same results. However, laparoscopy allows health-care professionals to see the endometriotic growth better and offers patients a faster recovery time.

After surgery, your health-care professional may recommend that you take combined hormonal contraception to lower the chances of your endometriosis returning and to better manage the symptoms of endometriosis.

It is important to know that not all women experience improvement after surgery, and for some women endometriosis may eventually return.

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. For women who have definitive surgery 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, 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 professional if you are considering incorporating alternative treatments into your lifestyle.