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The treatments
of endometriosis

Endometriosis is a chronic condition, the evolution of which is linked to menstrual cycles, covering the period from puberty to menopause, which can present itself in multiple forms, with little correlation between the severity of lesions and symptoms. These characteristics of the disease are arguments for personalized treatment of patients, based on symptoms, location of lesions, desire for pregnancy, but also the risks and adverse effects of the treatments.

The management of painful endometriosis can be achieved by using medication alone or combined with surgery.
Infertility due to endometriosis can be managed with assisted reproductive technology and/or surgery.

There is no specific treatment for endometriosis

Endometriosis can be treated either by surgery or by medical therapies, but most often by a combination of both.

As the origin and mechanisms for the development of endometriosis are not yet fully understood, there is no medical treatment specifically directed against endometriosis cells.

Medical treatment of endometriosis

Only one medical treatment approach is used at present, which blocks menstruation, using drugs that mimic either pregnancy or the menopause (the two physiological periods of absence of menstruation in the life of an adult woman).
In the vast majority of cases, this strategy makes it possible to stop the progression of endometriosis lesionsand to reduce painful symptoms, without however making them disappear.
Due to the blocking of ovulation, medical treatment is also contraceptive and its administration must be halted in women who wish to become pregnant.

Medical treatment involves achieving amenorrhea and has 2 main objectives:

  • improve painful symptoms by reducing inflammation and by its analgesic effect (non-steroidal anti-inflammatory drugs, different levels of analgesics)
  • stop the progression of lesions by blocking ovarian activity (continuous hormonal therapies such as estrogen-progestin pills, microprogestin pills that block ovulation, synthetic macroprogestin, GhRH agonists).

Hormonal therapies that inhibit ovarian activity

  • Are effective on pain and can stop the growth of lesions, provided that they are administered continuously (no periods).
  • When administered to patients who have undergone surgery, they significantly reduce risk of recurrences.
  • However, they have an unavoidable contraceptive effect and may lead to adverse effects that prompt patients to discontinue treatment (metrorhagia and spotting, weight gain, decreased libido, vaginal dryness, hot flashes, etc).
  • If treatment is stopped lesions are very likely to develop once again, and the impact of the treatment on pain is generally lost after a few months. For this reason, the treatment should be used until the age of menopause.

There is little scientific data on the long-term effectiveness of medical treatment. Consquently for a young woman aged 25 with endometriosis and prescribed medical treatment, the probability that she will avoid future surgery is presently unknown. The subsequent appearance of adenomyosis may alter the results of the medical treatment and make it difficult to achieve amenorrhea. The MESURE (MEdical versus Surgical management of Rectal Endometriosis) randomized trial, which compares the results of medical versus surgical treatment in women with rectal endometriosis, started in 2014 at Rouen University Hospital by Prof. Roman, with results expected in 2022, will provide more precise information on the effectiveness of each treatment in a given situation.

Nevertheless, medical treatment is not the ideal solution for all patients. Some women may experience side effects that cause them to discontinue taking hormonal medications, others may have medical contraindications to hormonal treatments (cardiovascular or hematological diseases, meningiomas, hormone-dependent tumors), and others may not be able to achieve amenorrhea (despite continuous hormonal treatments, frequent or constant uterine bleeding persists). In all these situations, corrective surgery remains the only alternative treatment.

Surgical treatment of endometriosis

The purpose of surgery is to resect or destroy endometriosis lesions and repair the affected organs for the purpose of treating pain and infertility. Long-term amenorrhea after surgery helps to prevent recurrence.

  • As a rule, the best results are obtained when patients receive a single, thorough surgical procedure, avoiding incomplete iterative surgeries.
  • The removal (resection) or ablation (destruction in situ) of superficial endometriosis lesions is a surgical procedure that most surgeons can perform.
  • The removal (cystectomy) or ablation of ovarian endometriomas can lead to a significant reduction in ovarian reserve with negative effects on fertility. The absence of a histological cleavage plane between the endometrioma itself and the ovarian parenchyma that surrounds it leads to frequent loss of ovarian tissue. Repeat surgery of recurrent endometriomas can lead to permanent ovarian failure. For this reason, other techniques can be considered for women with endometriomas on both ovaries, recurrent endometriomas, very large endometriomas, or those with low ovarian reserve: vaporization of the endometriomas (their destruction in situ using laser or plasma energy), sclerotherapy (destruction with alcohol), or simple drainage.
  • Surgery for deep endometriosis requires considerable expertise, and it is advisable for patients with this type of lesion to be referred to experienced teams. Depending on the position of the deep endometriosis nodules, surgery may require complex procedures on the digestive tract, urinary tract, sacral roots and diaphragm, requiring a multidisciplinary surgical team. The choice of surgery must take into account both the expected relief of symptoms and risk of postoperative complications.
  • Postoperative recurrence may occur before menopause, especially in women without hormonal treatment who continue to menstruate after surgery. Recurrence of pain does not automatically mean recurrence of the lesions and does not necessarily require repeat surgery.
  • In some cases, surgery may be performed in menopausal women who have fibrous nodules, which can have an obstructive effect on the colon, or make sexual intercourse painful or compress a nerve. In these cases, menopause does not lead to the disappearance of this type of nodule, which remains symptomatic despite the absence of menstruation.

Treatment of infertility

The medical treatment of endometriosis allowing amenorrhoea is automatically contraceptive, and a desire to conceive requires interruption of the treatment. A complete check-up should rapidly be carried out to look for other possible causes of infertility (dysovulation, sperm alterations, etc.) and an active approach should be taken on a case-by-case basis (natural fertilization, surgery and/or assisted reproduction) in order to avoid aggravation or recurrence of the disease.

for endometriosis
in numbers


of women undergoing surgery for colorectal endometriosis become pregnant within 5 years of surgery


of women undergoing surgery for colorectal endometriosis have no dysmenorrhea 5 years after surgery


of women operated for colorectal endometriosis have no period pain 5 years after surgery

Source : Roman et al, Hum reprod 2020


What is endometriosis?

Types of endometriosis

What are the types of endometriosis lesions?

The symptoms

What are the symptoms of endometriosis?

The diagnosis

How is endometriosis diagnosed?

Get support and advice from endometriosis specialists

For multidisciplinary management of endometriosis, IFEM Endo accompanies you throughout your care journey of medical and surgical treatment, medical follow-up and pain management.

Last updated on May 19, 2021 @ 10:02