B10. Treatment of endometriosis

Unfortunately, no treatment of endometriosis is curative. Rather, we can slow the progression and reduce the complaints of the patient. The goals of treatment are to:

• Achieve a pain-free state
• Solve infertility
• Remove ovarian endometrial cysts
• Remove endometrial lesions outside the lesser pelvis
• Achieve a long recurrence-free period

Treatment is indicated in cases of unacceptable pain, infertility if the patient wishes to have children, or there is risk of organ destruction. For example, DIE-induced hydronephrosis is an absolute indication for treatment because it can cause kidney destruction.

Hormonal therapy

Hormonal therapy is usually the first choice in the treatment of endometriosis.

The aim of hormonal therapy is to stop ovarian function, which prevents endometrial proliferation and therefore the symptoms and progression of endometriosis. This can be achieved with many types of drugs:

• Gestagen-only pill (minipill)
• Combined oral contraceptive pills (oestrogen-gestagen combination)
• Hormonal IUD (releases gestagens)
• Androgen derivates (danazol)
• GnRH analogues

The drug choice depends on the characteristics of the patient and the decision of the gynaecologist.

GnRH analogues virtually induces menopause, with all the symptoms and complications it brings with it.

Surgical treatment

With laparoscopy, endometriosis can be diagnosed and at the same time treated surgically by removing visible lesions. Removal of endometrial nodules surgically is the basic treatment to control symptoms. Pain relief is achieved in approx. 75% of patients who undergo surgical therapy.

During laparoscopy, the pelvis is explored and examined visually for lesions.

It’s important to perform imaging before laparoscopy to know the location of all the lesions, because if it’s determined during the surgery that not all lesions can be removed surgically, then we should rather remove no lesions than as many as we can. This is because removing some lesions but not all (suboptimal removal) is associated with dissemination and progression of the disease. If we’re not certain that we can make an optimal surgical intervention, it’s better to not remove any lesions and instead send the patient to a specialist.

Surgery may also be used to treat any adhesions which have appeared.

It is important to try to preserve the function of the organs when surgically removing endometrial nodules. For example, when treating a chocolate cyst, we only remove the wall of the cyst and not any ovarian tissue.

Surgical treatment of deep infiltrative endometriosis (DIE) is the most difficult surgical intervention in gynaecology. It’s usually treated in specialised centres.

Even after surgical removal of all visible nodules, there is a high chance (20 – 50%) that the condition will reappear after months or years. For this reason, surgical treatment should always be followed up by hormonal treatment.

Hysterectomy is an option for those who do not wish to retain the child-bearing ability and who are not sufficiently managed on conservative therapy or other surgery.