It’s still March, so it’s still Endometriosis Awareness Month! Today we’ll be looking at endometriosis treatment questions and answers. If you missed the first two posts in this series, you can click to read more about an overview of endometriosis as well as info about diagnosing endometriosis.

Why are there so many treatment options? Which one is best?

There are so many options because there is no “magic bullet” option — that is, no single treatment that works best for everyone. The two main categories of treatment include medication and surgery, but each option has its own benefits and drawbacks. When deciding on the best option for a given individual, some helpful questions to consider might be:

Do I have any current health concerns that would render some treatments unsafe? What types of health risks are acceptable to me?

Am I currently trying to conceive, or will I be in the next six to 12 months? Will I ever want to be pregnant in the future?

Aside from significant health risks, what types of factors — side effects, treatment frequency or duration, cost — would make a treatment difficult for me? How long do I need this treatment to last before I can reevaluate?

For specific questions, your best bet is to check with your health care provider.

OK. Assuming my doctor doesn’t know my answers to those questions yet, what’s likely to be the first recommended course of action?

For patients whose main issue is pain, doctors are likely to recommend some flavor of medication to suppress or atrophy that “rogue endometrium” — as surgical treatment doesn’t have improved results for pain and comes with its own complicating factors. That said, there appears to be conflicting evidence on which medical treatment of endo produces the best results. Options include:

Danazol or GnRH Analogues — Danazol, no longer widely used, is an androgenic agent; GnRH stands for “gonadotropin-releasing hormone,” and such analogues affect receptors in the pituitary gland. Both types of medications work by lowering estrogen levels in the body, which suppresses ovulation, menstruation, and endometriosis growth. Danazol has about a 90 percent success rate at reducing dysmenorrhea (painful periods), though it’s somewhat less effective for painful sex or chronic pelvic pain. There are multiple GnRH analogues (leuprolide acetate, or Lupron, is commonly prescribed for endo in the United States), but they have success rates that are similar to danazol.

In terms of side effects, danazol is associated with androgenic effects: weight gain, fluid retention, acne, and hirsutism (further growth of body hair). It’s also contraindicated in people with liver disease or high cholesterol. GnRH analogues, on the other hand, are associated with menopausal side effects: hot flashes, low libido, vaginal dryness, and mood swings. They also reduce bone mineral density. Because of their more serious side effects, treatment duration for both danazol and GnRH analogues is limited to six months. When the medications are discontinued, it’s common for endometriosis symptoms to begin to recur within a year.

Hormonal Contraceptives and/or Progestins** — Combined oral contraceptives suppresses the menstrual cycle, which can also shrink or slow the growth of endometriotic lesions. Progestins — i.e., synthetic progesterone, including forms of contraception like Depo-Provera and the Mirena IUD — can cause the endometrium both in and out of the uterus to atrophy, which is usually a good thing for folks with endometriosis.

Both combined hormone and progestin-only methods have their risks and side effects. However, they’re generally approximately as effective at treating pain (depending on the exact medication and the exact study) and are better tolerated for long-term use when compared to danazol or GnRH analogues. Additionally, these medications are often offered by primary care providers, including Planned Parenthood health centers, which may increase accessibility and affordability.

Primarily because of their side effects, which include that whole “shutting down reliable ovulation” thing, none of the above treatments is suitable for people who are looking to conceive a child in the very near future.

With all the different medications available, why do people still get surgery for endometriosis?

If a doctor identifies endometriosis during a diagnostic laparoscopy, it might be treated during the same surgery. Surgery is generally recommended for people wishing to become pregnant in the very near future because medical treatment of endo-associated infertility isn’t effective. Conservative surgery — that is, surgery designed to remove only the endo, leaving the rest of the organs intact — does appear to improve pregnancy rates, though there’s conflicting information regarding exactly how much those rates improve. Beyond that, surgery is also recommended for people who have not responded to medical treatments.

While there are risks to all surgery — from the anesthetic, from the possibility of infection — today most conservative surgery for endo is done via laparoscopy, which minimizes a lot of the risks. The other big consideration with surgery is the need for subsequent surgeries. According to one recent study, about 20 percent of folks will need an additional laparoscopy within two years; by seven years, about 55 percent will.

There’s also the possibility of definitive surgery — that is, hysterectomy (the removal of the uterus), usually including removal of the ovaries. As this is irreversible (compared to medical management) and extreme (compared to conservative surgery), it’s generally only recommended for people who don’t wish to preserve future fertility and who have already tried other methods. For people who are comfortable with its risks and benefits, hysterectomy does reduce the need for additional surgeries when compared to conservative surgery. However, up to 15 percent of people may experience recurrent endo symptoms even after hysterectomy and ovary removal.

That’s it? Are surgery and hormone-altering treatments my only options?

Newer research is always emerging, but surgery and the above medications are the current main treatment options — techniques designed to reduce the endometriotic implants as well as relieve symptoms. But there are management options that can lessen symptoms without addressing the cause. (Given that some management options have fewer side effects than the above, this is not always a deal breaker.) Though in most cases, large-scale, controlled studies are lacking (unless you’ve found some! In which case, link in the comments!), some individuals with endo find full or partial relief with pain relieving medications, diet, and physical therapy.

The whole thing can be pretty complicated, and it’s impossible to determine an individual “best” endo treatment or management strategy via one blog post. Determining a game plan is often a process, and it’s something that should involve both the patient and a health care provider who knows and understands them well.

** Most if not all of the specific progestins used to treat endometriosis are ones also available in hormonal contraceptives, though the prescribing doses may be different.