Understanding Treatment for Endometriosis

What is endometriosis? This condition occurs when tissue similar to that lining the uterus (endometrial tissue) is found outside the uterus, ovaries, fallopian tubes, bladder, or intestines. Although its cause isn’t clear, some researchers think endometriosis may happen after endometrial tissue from menstrual flow travels backwards through the fallopian tubes and out into the pelvic cavity. As this tissue grows in the pelvis, a variety of biochemical and immune changes occur, but it’s not clear which are the causes and which are the result of the disease.^1,2

Signs and symptoms. Affecting about 1 in 10 women, endometriosis causes pain and scarring (adhesions). Up to half experience infertility. Some women have no symptoms, but others experience pain or heavy bleeding during menstruation, painful intercourse, chronic pelvic pain, or other urinary or gastrointestinal symptoms. In most cases, symptoms and tests can reliably implicate endometriosis.

Doctors can confirm a diagnosis with a surgical procedure called a laparoscopy, which uses a thin, lighted tube placed through a small abdominal incision to examine the pelvic organs. At this time, a sample of tissue is removed and examined under a microscope (biopsy). The surgeon may surgically treat the condition at the same time, by excising or removing as much visible growing tissue as possible.^2,3,4

Impact on fertility. Endometriosis can be less thick (superficial) or deeply invasive and may impair fertility in one or more ways:

• Scar and distort pelvic anatomy such as fallopian tubes
• Cause growth of “chocolate cysts” (endometriomas) in the ovaries
• Thicken the uterus (called adenomyosis), which may interfere with implantation
• Inflame pelvic structures
• Change how the pelvic immune system functions
• Alter the eggs’ quality or hormonal environment^3,5

Your chances of getting pregnant depend mainly upon the severity of the disease—its amount, location, and depth—ranked from mild (Stage 1), which has a better chance of success, to severe (Stage 4), which has a low chance of success.³

Treatment options. Treatment doesn’t cure the condition, but it may help relieve symptoms and improve pregnancy outcomes. If symptoms aren’t a problem, you may not need treatment at all.

Treatment is highly personalized. What’s best for you depends upon the severity of your symptoms, as well as your age, desire to become pregnant, and potential for poor responses to certain therapies. In severe cases, both medical and surgical treatment will improve pain.¹

In brief, these are your medical and surgical options:

• Analgesics, oral contraceptives, or hormonal treatment to help manage pain
• Surgery to remove (excise or ablate) endometriosis
• Cystectomy to remove ovarian endometriosis

If you need surgery for deep infiltrating endometriosis, it’s best to have this done by an experienced surgeon since complication rates can be high.⁴

Management of infertility. What’s unique, if anything, about the treatment of women who want to become pregnant—now or in the future? For starters, it’s a good idea to talk with a fertility specialist to better understand which options might work best for you—even if you’re not quite ready to pursue getting pregnant.

Discussing options early is even more important if you’re over 30 or have fewer eggs (poor ovarian reserve.) Surgery may remove adhesions and restore normal anatomy and improve pregnancy rates, but if ovaries are involved, surgery may also lower your ovarian reserve. If you need surgery, you might want to consider first freezing your eggs for future use.^1,2

In some cases, doctors may recommend both medical and surgical treatment. It's important to realize that while medical treatments may help pain management, they don’t improve fertility outcomes.^2,3,4

When recommending treatment, your physician will also consider whether you have superficial or deep endometriosis or adenomyosis. Trying to remove deep endometriosis in addition to superficial endometriosis may not improve your chances of pregnancy.⁵

In vitro fertilization. If you have Stage 3 or 4 endometriosis, in vitro fertilization (IVF) is likely your best option.

Studies haven’t confirmed whether or not surgery before IVF is helpful. But if IVF has failed many times or if symptoms aren’t responding to medical therapy, it may be best to first pursue surgery. ^5,6

Unless your endometriosis is severe, know that your chances of giving birth with IVF are comparable to those of women without endometriosis.⁶ If you have severe adenomyosis, however, you may need to consider using a gestational carrier.

Sources

1. Cleveland Clinic: Endometriosis
2. RESOLVE: Endometriosis and Infertility: What You Need to Know
3. ASRM: Endometriosis: Does It Cause Infertility?
4. Medscape: New Guideline: Management of Women with Endometriosis
5. Medscape: The Management of Endometriosis-related Infertility
6. Hamdan M et al. Obstet Gynecol. 2015;125(1):79–88.

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