Treatment needs to be tailored according to the patient’s symptoms, expectations and circumstances. The woman should be involved in the decision-making when selecting the appropriate treatment. Endometriosis may sometimes be an incidental finding and no treatment may be needed if the woman is entirely symptom free. When treatment is needed it is important to have a multidisciplinary approach to ensure that the woman has access to appropriate surgical or medical treatment expertise, pain management, psychological support and fertility advice. For this reason in many countries including the United Kingdom there is a trend towards establishing endometriosis centres where patients can find all this expertise in one place. These centres usually have gynaecological surgeons with advanced minimal access (keyhole) surgery experience, colorectal and urological surgeons, fertility specialists, pain management specialists, psychologists or counsellors, clinical nurse specialists and sometimes complimentary medicine practitioners.
Surgical treatment of endometriosis
Surgical treatment of endometriosis is probably the most effective form of treatment. There is evidence from randomised controlled trials that surgical treatment is effective in improving pain associated with endometriosis. Comparative trials show improvement of pain or quality of life in approximately 60-70% of women following surgical treatment of endometriosis. Surgical treatment also improves chances of natural pregnancy in couples who have endometriosis associated infertility. A review of randomised controlled trials showed approximately 1.6 times higher spontaneous pregnancy rates following surgery for early endometriosis compared to no treatment. The evidence on the effectiveness of surgery in advanced endometriosis comes from retrospective case series and there are no randomised controlled trials.
Medical treatment of endometriosis
Some women choose medical treatment instead of surgery; medical treatment may also be necessary when symptoms persist after surgery or when surgical treatment is not possible or appropriate. The most commonly used medical treatment approaches are the combined oral contraceptive pill, levonorgestrel intrauterine system (Mirena®), gonadotrophin releasing hormone analogues (GnRHa) or progestogens (progesterone hormone derivatives). These options are usually equally effective in controlling the symptoms of endometriosis; however they do not eliminate it. Hence the recurrence of symptoms after discontinuation of treatment is very common. The side effect profile of these drugs varies and the duration they can be used depends on their side effect profile.
Endometriosis and infertility treatment
Some women with endometriosis will experience fertility difficulties. Medical (hormonal) treatment has no place in the treatment of endometriosis associated infertility. They all have contraceptive effects and would delay pregnancy; they do not increase the likelihood of pregnancy after discontinuation of treatment either.