There are various approaches to managing endometriosis’ symptoms and signs. Many women employ a variety of approaches during each menstrual cycle, and an even broader range of approaches across their whole lifespan. Sometimes, lifestyle and non-hormonal strategies are sufficient. At other times, or for other patients, a variety of stronger approaches are needed. Please discuss with your clinician which approach(es) are worth considering, in your particular situation.

Allied health

Clinical psychologist

If you have persistent pelvic pain, a clinical psychologist is likely to become a vital part of your multidisciplinary treating team. If you are referred to the psychologist, it is not because your doctor thinks “it’s all in your head’, but rather that the traditional methods of dealing with your symptoms have been of limited help to control your pain.

Consulting with a clinical psychologist can help with your perception of your endometriosis symptoms, such as persistent pelvic pain. Paradoxically, these symptoms can occur even in the absence of active endometriosis; this can be indicative of problems with your nervous system’s processing of pain signals.

A clinical psychologist who specialises in pain management may be able to help, by teaching you how to use specific strategies to cope with persistent pain, anxiety, and depression.

Pelvic physiotherapist

Qualified pelvic physiotherapists (such as Maven Centre’s Cara Richmond) have many assessment and treatment strategies, that can help with the persistent pelvic pain that is often associated with endometriosis. These strategies include:

• Pelvic floor muscle assessment and relaxation exercises
• Bladder retraining exercises
• Functional bowel exercises and retraining
• Transcutaneous electrical nerve stimulation (TENS). There is reasonable evidence to support the use of TENS in relieving period pain. These machines are discrete, patient-controlled devices, that can be used while at home or work. In general, they are well-tolerated, have minimal side-effects, and can help to reduce the amount of pain relief medications patients with endometriosis need to take.

Dietetician

There is some evidence that diet plays a role in endometriosis symptomatology. It is worth discussing with a qualified dietician (such as Maven Centre’s Dr Stephanie Pirotta) if the following dietary modifications would be worthwhile:

• Maintaining a balanced diet rich in nutrients, and low in processed and refined foods
• Incorporating vegetables, legumes and whole grains rich in folic acid, methionine, zinc, vitamin B12, vitamin B6, and vitamins A, C, D and E
• Decreasing red meat intake
• Decreasing caffeine intake
• Increasing intake of foods rich in omega-3 fatty acids, or taking a fish oil supplement
• Increasing intake of foods rich in polyphenols (eg. citrus fruits, apples, green tea, olive oil, and chocolate)
• Increasing turmeric (or ‘curcumin’) intake

There is some evidence that, for women who suffer from both endometriosis and irritable bowel syndrome (IBS), a low-FODMAP diet may improve their symptoms.

More (especially higher-level) research is needed to draw conclusions regarding the effectiveness of dietary interventions on pelvic pain and disease recurrence and progression in women with endometriosis.

Complementary medicine

Complementary medicine are treatments you may receive alongside with traditional Western medicine and qualified allied health clinicians (such as physiotherapists and dieticians). Examples of complementary medicine, in the endometriosis context include:

• Acupuncture. Approximately 40% of women with endometriosis who have twice-weekly acupuncture report that it helps manage at least some of their symptoms
• Mindfulness meditation can be used by patients during pain flares. Mindfulness-based interventions include: deep-breathing exercises, guided imagery, hypnotherapy, and progressive relaxation.
• Yoga. One study (based in Brazil) reported that women who completed two 90 minute yoga sessions every week for eight weeks experienced a significant improvement in their daily pain.

Endometriosis Australia have suggested that the benefits of complementary medicine for women with endometriosis include that it may:

• Reduce pain
• Improve mood
• Improve general health and wellbeing

Using complementary medicine to self-manage pain flares gives many patients agency over their endometriosis symptoms. Much more high-level research is needed, before any complementary therapies can be confidently supported. However, complementary medicine can employed as part of a multidisciplinary, team-based approach to managing your endometriosis symptoms.

Pain relief

Non-hormonal medicines are often used to treat the symptoms of endometriosis. They may include:

• Pain relief tablets, such as paracetamol, naprogesic, and ibuprofen
• Mefenamic acid (or ‘Ponstan’) during periods

These medications can be used on an ‘as needed’ basis (for example, during your period to help with your period pain).

Cannabidiol (CBD) oil

A recent systematic review concluded that medicinal cannabis has the potential to be a relatively safe and effective treatment for persistent pelvic pain. Medicinal cannabis can be accessed in Australia using the government’s Special Access Scheme, and an eligible prescriber.

With appropriate counselling, CBD oil may be used as an adjunct to standard medical and surgical approaches. Please read Endometriosis Australia’s blog regarding medicinal cannabis in endometriosis, by clicking on this link.

Hormonal contraception

As outlined in this blog post, the most widely-held theory is that endometriosis is caused by a process caused ‘retrograde menstruation’. Logically, anything that can lighten a woman’s period will slow this process, thereby slowing the pace at which endometriosis develops and grows. In some women, so-called ‘hormonal suppression’ is effective in reducing endometriosis-related pain.

The hormonal approaches outlined below essentially all function as contraception, so unfortunately are counterproductive if you are trying to conceive.

Hormonal suppression can help with minimal (stage I) or mild (stage II) endometriosis. But it cannot ‘dissolve’ large endometriotic ovarian cysts, nor reverse endometriosis-related internal scarring. It is also less effective to manage pain with sex, or the persistent pelvic pain (that occurs between periods), which are both common issues for women with endometriosis.

Combined (estrogen + progestin) oral contraceptive pill

The most common form of hormonal suppression to help manage endometriosis is the combined oral contraceptive pill. This has been shown to lighten periods by approximately 60%; one study found that (on average), women with endometriosis find a 50% improvement in their period pain when on The Pill.

Progesterone-only contraception

Some clinicians recommend progesterone-only contraceptives over a combined estrogen + progesterone pill, based on the fact that endometriosis growth is driven by estrogen. Taking continuous progesterone-only contraceptive often stops regular periods altogether; progestins also have anti-inflammatory properties, which may help alleviate inflammation and pain associated with endometriosis.

There are various forms of contraception that only contain progesterone, without any estrogen ingredient. These include the:

• Progesterone-only pill
• Implanon: small plastic rod that is inserted under the skin of your upper arm
• Mirena intrauterine device
• Depo-Provera: insertion of a progesterone ‘pellet’ into the skin of your tummy every three months

One study found that two thirds of women with endometriosis notice a significant improvement in their period pain when they take progesterone-only contraception.

GnRH agonists

In certain situations, your gynaecologist may recommend that you take a few months of strong medications to put you into a temporary menopause. These medications are of a class called ‘gonadotrophin-releasing hormone agonist’, or ‘GnRH agonist’ (for short). They block the menstrual cycle, and lower oestrogen levels. This causes the endometriosis tissue to shrink, and also brings on an artificial (and temporary) menopause.

Examples of these medications are goserelin (or ‘Zoladex’), and nafarelin (or ‘Synarel’). These medications should stop your periods all together, and relieve any endometriosis-related symptoms. If taken for more than six months, these medicines can cause irreversible osteoporosis, so they are only used short-term, in specific situations.

GnRH antagonists

A medicine that has recently been released onto the Australian market is ‘Ryeqo’. Like the GnRH agonists mentioned above, Ryeqo will put you into a temporary menopause: your periods should stop, and (logically) any period pain should also resolve. Unlike GnRH agonists, ‘Ryeqo’ can be taken indefinitely – not just for six months. It currently costs approximately $135 / month out-of-pocket, which for some women may be prohibitive.

Topic area frequently asked questions (FAQs)

Do any medicines slow the regrowth of endometriosis after surgery?

Studies have shown there is a delay in endometriosis recurring if surgery is followed by treatment with GnRH agonists, the contraceptive pill or the Mirena intrauterine device. Hence, your gynaecologist may suggest that you go onto one of these hormonal treatments after your laparoscopic (keyhole) surgery.

What if I want to conceive?

All of the hormonal medicines mentioned above act as contraception. Hence, they’re not appropriate if you’re trying to conceive. It is safe to take over-the-counter pain relief (eg. naprogesic, ibuprofen, mefenamic acid) during your period, even if you are trying to conceive.

What is the best treatment for endometriosis?

There is no ‘best treatment’, since treatments will work differently for everyone. You should be aware of the different kinds of treatments, and their possible effects, side effects and/or complications. A combination of treatments can be used to assist in the relief of symptoms associated with endometriosis.

Many gynaecologists feel that the best combination of treatments is: keyhole surgery to look for and remove any pre-existing endometriosis; then hormonal suppression to slow its regrowth (unless you are actively trying to fall pregnant).

Conclusion

Broadly speaking, there are several options regarding the non-surgical management of endometriosis, including: allied health (such as pelvic physiotherapy and dietetics); complementary medicine (eg. acupuncture); over-the-counter pain relief; and hormonal suppression. Discuss your preferred options with your clinician, to find what works best for you!

The next blog post in this series of endometriosis-related posts will discuss surgical management of endometriosis.