Treatment must be tailored to the patient’s symptoms, expectations, and circumstances. The woman must participate in decision-making when selecting the appropriate treatment. Endometriosis can sometimes be an incidental finding, and treatment may not be needed if the woman has no symptoms. When treatment is needed, it is important to have a multidisciplinary approach to ensure that the woman has access to appropriate expertise in medical or surgical treatment, pain management, psychological support, and fertility counseling. For this reason, in many countries, including the UK, there is a trend to establish endometriosis centers where patients can find all this expertise in one place. These centers typically have gynecologic surgeons with advanced experience in minimal access (keyhole) surgery, colorectal and urologic surgeons, fertility specialists, pain management specialists, psychologists or counselors, clinical nurse specialists, and sometimes adjunct physicians.
Surgical treatment of endometriosis.
Surgical treatment of endometriosis is probably the most effective form of treatment. There is evidence from randomized controlled trials that surgical treatment is effective in improving pain associated with endometriosis. Comparative trials show an improvement in pain or quality of life in approximately 60-70% of women after surgical treatment of endometriosis. Surgical treatment also improves the chances of a natural pregnancy in couples who have endometriosis-associated infertility. A review of randomized controlled trials showed spontaneous pregnancy rates approximately 1.6 times higher after surgery for early endometriosis compared with no treatment. The evidence for the effectiveness of surgery in advanced endometriosis comes from retrospective case series and there are no randomized controlled trials.
Medical treatment of endometriosis.
Some women choose medical treatment instead of surgery; Medical treatment may also be necessary when symptoms persist after surgery or when surgical treatment is not possible or appropriate. The most widely used medical treatment approaches are the combined oral contraceptive pill, levonorgestrel intrauterine system (Mirena®), gonadotropin-releasing hormone (GnRHa) analogues, or progestogens (derivatives of the hormone progesterone). These options are often just as effective in managing endometriosis symptoms; however, they do not eliminate it. Therefore, the reappearance of symptoms after stopping treatment is very common. The side effect profile of these drugs varies and the duration of their use depends on your side effect profile.
Treatment of endometriosis and infertility
Some women with endometriosis will experience fertility difficulties. Medical (hormonal) treatment has no place in the treatment of infertility associated with endometriosis. All have contraceptive effects and would delay pregnancy; they also do not increase the likelihood of pregnancy after treatment is stopped.