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While surgery can reduce endometriosis symptoms and increase your chances of getting pregnant, medications are usually suggested first. What pharmacological treatments are often recommended in the management of endometriosis?

There is no definitive cure for endometriosis — a chronic and painful condition in which the uterine lining overgrows in other areas of the reproductive system and beyond. Treatment approaches may aim to reduce the amount of pain you have to endure, increase your fertility, or reduce the growth of extrauterine endometrial tissues. Less invasive treatments options will typically be explored first, with surgery being an option for women with more severe symptoms and those who are trying to conceive.

What pharmacological treatments will your healthcare provider most likely recommend to help you improve your quality of life with endometriosis?

Pain reduction

Painkillers are an almost inevitable part of any approach to treating a condition in which chronic pain is involved. To help you deal with the pain your endometriosis induces, your healthcare provider will initially recommend over-the-counter pain relievers. Those belonging to the nonsteroidal anti-inflammatory (NSAID) class of medications will simultaneously reduce pain and inflammation. Examples include:

  • Ibuprofen (Advil, Motrin, IBU, Proprinal, and many other brand names)
  • Naproxen (Aleve, Synflex, Anaprox, Feminax Ultra, others)
It is important to be aware that some studies have shown NSAIDs to be ineffective in reducing endometriosis-related menstrual pain, as well as that taking them regularly can induce serious side effects, however. If over-the-counter analgesics are not coming close to offering you any relief, talk to your doctor about the benefits and risks of prescription pain meds instead.

Hormone therapy

Since endometriosis is an estrogen-dependent condition, hormone therapy has the goal of reducing estrogen production in the body. This, in turn, slows the growth of existing extrauterine endometrial lesions, helps prevent the development of new ones, and should reduce your symptoms. Hormone therapy, which comes in several forms, is not a permanent cure for endometriosis. Patients should also be aware that it can lead to side effects, including depression, irregular menstrual bleeding, and weight gain.

 Hormone therapies your doctor may suggest are:

  • Combined hormonal contraceptives, including the birth control pill
  • Progestins
  • Gonadotrophin-releasing hormone (GnRH) agonists
  • Aromatase inhibitors, which halt estrogen production

Combined hormonal contraceptives

Combined hormonal contraceptives contain both estrogen and progestin. They include many birth control pills as well as the vaginal ring and birth control patch. Primarily designed to prevent pregnancy, they can help women with endometriosis who are not planning to conceive reduce pain and lighten their menstrual flow.

Women with endometriosis who opt to take combined oral contraceptives will be told to take the pill continuously (without a break) for three consecutive months. If the treatment is successful in reducing your pain or even eliminating it altogether, you can then continue taking the pill.

Endometriosis patients who stop using the pill after a year enjoy higher pregnancy rates, so this may even be a strategy to increase your chances of conceiving. Another benefit of this treatment option is that the pill reduces a woman's risk of developing epithelial ovarian cancer, a disease endometriosis sufferers have a slightly increased risk of. 

Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists

Gonadotropin-releasing hormone (Gn-RH) agonists (commonly used ones including goserelin/Zoladex and leuprolide/Lupron Depot, Eligard) and antagonists are both used in the treatment of endometriosis patients with more intense symptoms. Gonadotropin-releasing hormone agonists reduce pain for the vast majority of women, and this pain reduction lasts for more than six months after the treatment has been completed.

Your treatment regime may include:

  • A combination of desogestrel and ethinyl estradiol, used to lower estrogen levels, halt the further growth of endometrial lesions, and reduce their size. This treatment further stops you from menstruating, thereby putting an end to heavy periods. Pills with larger doses of progestin seem to be more effective at providing symptom relief. 
  • Norgestimate and ethinyl estradiol, in combination, reduce your levels of gonadotropin-releasing hormones, in turn also decreasing your levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). 
  • Elagolix (Orilissa), a GnRH antagonist, was FDA-approved specifically to treat moderate and severe endometriosis-related pain. It can also be used in the treatment of uterine fibroids, which are not uncommon in endometriosis patients. 
These medications reduce your estrogen levels, which very frequently leads to menopause symptoms like hot flashes, night sweats, mood swings, vaginal dryness, acne, and headaches. This is why low doses of estrogen or progestin are often recommended as so-called "add-back medications", to reduce these side effects. While you cannot conceive for the period of time you are using this medication regime, your fertility should return soon after you cease using these medications. These drugs also lead to some bone density loss. To reduce your risk of developing osteoporosis later on, the regime is will not be used for longer than six months to allow your bones to regenerate. 

Danazol

Danazol (Danocrine) is an anti-estrogen, androgen, and steroid that was the most popular treatment for women with endometriosis before GnRH agonists appeared on the market. Danazol stops you from menstruating, thereby offering you relief from heavy and painful periods, and reduces endometrial lesions. It is generally used for up to six months at a time, and women currently taking Danazol should avoid getting pregnant. Because Danazol is an androgen (male hormone), some of its side effects may include a deeper voice, more body hair, and smaller breasts. This is one of the reasons the medication is not popular now.

Progestin therapy with progestational agents

Progestin-only treatments include the Mirena intrauterine system, Nexplanon, Depo Provera, and progestin-only birth control pills like Aygestin, Camila, and Errin. These treatments reduce estrogen levels and thus reduce your pain, put a stop to your periods, and prevent the further proliferation of endometrial lesions.

Aromatase inhibitors

Aromatase inhibitors like letrozole (Femara) reduce estrogen levels, and are used as part of breast cancer treatment. They have not, thus far, been extensively studied in the context of endometriosis treatment, but are sometimes used off-label in endometriosis patients who are not trying to get pregnant when other treatments have proven to be inadequate. In these cases, it is combined with hormonal contraceptives.

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