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Overview of the treatment of endometriosis

Robert S Schenken, MD
Section Editor
Robert L Barbieri, MD
Deputy Editor
Kristen Eckler, MD, FACOG


According to the Practice Committee of the American Society for Reproductive Medicine, “endometriosis should be viewed as a chronic disease that requires a life-long management plan with the goal of maximizing the use of medical treatment and avoiding repeated surgical procedures” [1]. Despite extensive research, the optimal management of endometriosis is unclear. This topic will review medical and surgical options for treating women with this disease. Clinical features and diagnosis of endometriosis, as well as management of thoracic endometriosis, are discussed separately. (See "Endometriosis: Pathogenesis, clinical features, and diagnosis" and "Clinical features, diagnostic approach, and treatment of adults with thoracic endometriosis".)


Clinical manifestations of endometriosis fall into three general categories: pelvic pain, infertility, and pelvic mass. The goal of therapy is to relieve these symptoms. There is no high quality evidence that one medical therapy is superior to another for managing pelvic pain due to endometriosis, or that any type of medical treatment will affect future fertility. Therefore, treatment decisions are individualized, taking into account the severity of symptoms, the extent and location of disease, whether there is a desire for pregnancy, the age of the patient, medication side effects, surgical complication rates, and cost.

Treatment options include:

Expectant management



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Literature review current through: Jan 2016. | This topic last updated: Oct 7, 2015.
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  1. Practice Committee of American Society for Reproductive Medicine. Treatment of pelvic pain associated with endometriosis. Fertil Steril 2008; 90:S260.
  2. Mahmood TA, Templeton A. The impact of treatment on the natural history of endometriosis. Hum Reprod 1990; 5:965.
  3. Vessey MP, Villard-Mackintosh L, Painter R. Epidemiology of endometriosis in women attending family planning clinics. BMJ 1993; 306:182.
  4. Moen MH. Is a long period without childbirth a risk factor for developing endometriosis? Hum Reprod 1991; 6:1404.
  5. Parazzini F, La Vecchia C, Franceschi S, et al. Risk factors for endometrioid, mucinous and serous benign ovarian cysts. Int J Epidemiol 1989; 18:108.
  6. American College of Obstetricians and Gynecologists. ACOG Committee Opinion. Number 310, April 2005. Endometriosis in adolescents. Obstet Gynecol 2005; 105:921.
  7. ACOG Committee on Practice Bulletins--Gynecology. ACOG practice bulletin. Medical management of endometriosis. Number 11, December 1999 (replaces Technical Bulletin Number 184, September 1993). Clinical management guidelines for obstetrician-gynecologists. Int J Gynaecol Obstet 2000; 71:183.
  8. Dunselman GA, Vermeulen N, Becker C, et al. ESHRE guideline: management of women with endometriosis. Hum Reprod 2014; 29:400.
  9. American College of Obstetricians and Gynecologists. Medical management of endometriosis. ACOG practice bulletin 11, American College of Obstetricians and Gynecologists, Washington, DC 1999.
  10. Hughes E, Brown J, Collins JJ, et al. Ovulation suppression for endometriosis. Cochrane Database Syst Rev 2007; :CD000155.
  11. Allen C, Hopewell S, Prentice A, Gregory D. Nonsteroidal anti-inflammatory drugs for pain in women with endometriosis. Cochrane Database Syst Rev 2009; :CD004753.
  12. Harada T, Momoeda M, Taketani Y, et al. Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis: a placebo-controlled, double-blind, randomized trial. Fertil Steril 2008; 90:1583.
  13. Buttram VC Jr. Cyclic use of combination oral contraceptives and the severity of endometriosis. Fertil Steril 1979; 31:347.
  14. Strathy JH, Molgaard CA, Coulam CB, Melton LJ 3rd. Endometriosis and infertility: a laparoscopic study of endometriosis among fertile and infertile women. Fertil Steril 1982; 38:667.
  15. Kirshon B, Poindexter AN 3rd. Contraception: a risk factor for endometriosis. Obstet Gynecol 1988; 71:829.
  16. Mahmood TA, Templeton A. Prevalence and genesis of endometriosis. Hum Reprod 1991; 6:544.
  17. Moen MH. Endometriosis in women at interval sterilization. Acta Obstet Gynecol Scand 1987; 66:451.
  18. Vercellini P, Trespidi L, Colombo A, et al. A gonadotropin-releasing hormone agonist versus a low-dose oral contraceptive for pelvic pain associated with endometriosis. Fertil Steril 1993; 60:75.
  19. Davis L, Kennedy SS, Moore J, Prentice A. Modern combined oral contraceptives for pain associated with endometriosis. Cochrane Database Syst Rev 2007; :CD001019.
  20. Zupi E, Marconi D, Sbracia M, et al. Add-back therapy in the treatment of endometriosis-associated pain. Fertil Steril 2004; 82:1303.
  21. Guzick DS, Huang LS, Broadman BA, et al. Randomized trial of leuprolide versus continuous oral contraceptives in the treatment of endometriosis-associated pelvic pain. Fertil Steril 2011; 95:1568.
  22. Vercellini P, Frontino G, De Giorgi O, et al. Continuous use of an oral contraceptive for endometriosis-associated recurrent dysmenorrhea that does not respond to a cyclic pill regimen. Fertil Steril 2003; 80:560.
  23. Vercellini P, Barbara G, Somigliana E, et al. Comparison of contraceptive ring and patch for the treatment of symptomatic endometriosis. Fertil Steril 2010; 93:2150.
  24. Brown J, Pan A, Hart RJ. Gonadotrophin-releasing hormone analogues for pain associated with endometriosis. Cochrane Database Syst Rev 2010; :CD008475.
  25. Ling FW. Randomized controlled trial of depot leuprolide in patients with chronic pelvic pain and clinically suspected endometriosis. Pelvic Pain Study Group. Obstet Gynecol 1999; 93:51.
  26. Luciano AA, Turksoy RN, Carleo J. Evaluation of oral medroxyprogesterone acetate in the treatment of endometriosis. Obstet Gynecol 1988; 72:323.
  27. Telimaa S, Puolakka J, Rönnberg L, Kauppila A. Placebo-controlled comparison of danazol and high-dose medroxyprogesterone acetate in the treatment of endometriosis. Gynecol Endocrinol 1987; 1:13.
  28. Prentice A, Deary AJ, Bland E. Progestagens and anti-progestagens for pain associated with endometriosis. Cochrane Database Syst Rev 2000; :CD002122.
  29. Crosignani PG, Luciano A, Ray A, Bergqvist A. Subcutaneous depot medroxyprogesterone acetate versus leuprolide acetate in the treatment of endometriosis-associated pain. Hum Reprod 2006; 21:248.
  30. Vercellini P, Cortesi I, Crosignani PG. Progestins for symptomatic endometriosis: a critical analysis of the evidence. Fertil Steril 1997; 68:393.
  31. Dawood MY, Obasiolu CW, Ramos J, Khan-Dawood FS. Clinical, endocrine, and metabolic effects of two doses of gestrinone in treatment of pelvic endometriosis. Am J Obstet Gynecol 1997; 176:387.
  32. Regidor PA, Regidor M, Schmidt M, et al. Prospective randomized study comparing the GnRH-agonist leuprorelin acetate and the gestagen lynestrenol in the treatment of severe endometriosis. Gynecol Endocrinol 2001; 15:202.
  33. Schlaff WD, Carson SA, Luciano A, et al. Subcutaneous injection of depot medroxyprogesterone acetate compared with leuprolide acetate in the treatment of endometriosis-associated pain. Fertil Steril 2006; 85:314.
  34. Vercellini P, De Giorgi O, Oldani S, et al. Depot medroxyprogesterone acetate versus an oral contraceptive combined with very-low-dose danazol for long-term treatment of pelvic pain associated with endometriosis. Am J Obstet Gynecol 1996; 175:396.
  35. Abou-Setta AM, Al-Inany HG, Farquhar CM. Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic endometriosis following surgery. Cochrane Database Syst Rev 2006; :CD005072.
  36. Wong AY, Tang LC, Chin RK. Levonorgestrel-releasing intrauterine system (Mirena) and Depot medroxyprogesterone acetate (Depoprovera) as long-term maintenance therapy for patients with moderate and severe endometriosis: a randomised controlled trial. Aust N Z J Obstet Gynaecol 2010; 50:273.
  37. Vercellini P, Frontino G, De Giorgi O, et al. Comparison of a levonorgestrel-releasing intrauterine device versus expectant management after conservative surgery for symptomatic endometriosis: a pilot study. Fertil Steril 2003; 80:305.
  38. Petta CA, Ferriani RA, Abrao MS, et al. Randomized clinical trial of a levonorgestrel-releasing intrauterine system and a depot GnRH analogue for the treatment of chronic pelvic pain in women with endometriosis. Hum Reprod 2005; 20:1993.
  39. Bayoglu Tekin Y, Dilbaz B, Altinbas SK, Dilbaz S. Postoperative medical treatment of chronic pelvic pain related to severe endometriosis: levonorgestrel-releasing intrauterine system versus gonadotropin-releasing hormone analogue. Fertil Steril 2011; 95:492.
  40. Tanmahasamut P, Rattanachaiyanont M, Angsuwathana S, et al. Postoperative levonorgestrel-releasing intrauterine system for pelvic endometriosis-related pain: A randomized trial. Obstet Gynecol 2012.
  41. Walch K, Unfried G, Huber J, et al. Implanon versus medroxyprogesterone acetate: effects on pain scores in patients with symptomatic endometriosis--a pilot study. Contraception 2009; 79:29.
  42. Yisa SB, Okenwa AA, Husemeyer RP. Treatment of pelvic endometriosis with etonogestrel subdermal implant (Implanon). J Fam Plann Reprod Health Care 2005; 31:67.
  43. Strowitzki T, Marr J, Gerlinger C, et al. Dienogest is as effective as leuprolide acetate in treating the painful symptoms of endometriosis: a 24-week, randomized, multicentre, open-label trial. Hum Reprod 2010; 25:633.
  44. Cirkel, U, Schweppe, KW, Ochs, H, et al. Effects of LHRH agonist therapy in the treatment of endometriosis. In: Gonadotropin down-regulation in gynecological practice. Vol 225, Chadha, DR, Willemsen, WNP (Eds). Aln R Liss, New York 1986. p. 189.
  45. Chwalisz K, Perez MC, Demanno D, et al. Selective progesterone receptor modulator development and use in the treatment of leiomyomata and endometriosis. Endocr Rev 2005; 26:423.
  46. Spitz IM. Clinical utility of progesterone receptor modulators and their effect on the endometrium. Curr Opin Obstet Gynecol 2009; 21:318.
  47. Barbieri RL, Evans S, Kistner RW. Danazol in the treatment of endometriosis: analysis of 100 cases with a 4-year follow-up. Fertil Steril 1982; 37:737.
  48. Selak V, Farquhar C, Prentice A, Singla A. Danazol for pelvic pain associated with endometriosis. Cochrane Database Syst Rev 2007; :CD000068.
  49. Attar E, Bulun SE. Aromatase inhibitors: the next generation of therapeutics for endometriosis? Fertil Steril 2006; 85:1307.
  50. Bulun SE, Zeitoun K, Takayama K, et al. Estrogen production in endometriosis and use of aromatase inhibitors to treat endometriosis. Endocr Relat Cancer 1999; 6:293.
  51. Razzi S, Fava A, Sartini A, et al. Treatment of severe recurrent endometriosis with an aromatase inhibitor in a young ovariectomised woman. BJOG 2004; 111:182.
  52. Takayama K, Zeitoun K, Gunby RT, et al. Treatment of severe postmenopausal endometriosis with an aromatase inhibitor. Fertil Steril 1998; 69:709.
  53. Ailawadi RK, Jobanputra S, Kataria M, et al. Treatment of endometriosis and chronic pelvic pain with letrozole and norethindrone acetate: a pilot study. Fertil Steril 2004; 81:290.
  54. Shippen ER, West WJ Jr. Successful treatment of severe endometriosis in two premenopausal women with an aromatase inhibitor. Fertil Steril 2004; 81:1395.
  55. Amsterdam LL, Gentry W, Jobanputra S, et al. Anastrazole and oral contraceptives: a novel treatment for endometriosis. Fertil Steril 2005; 84:300.
  56. Hefler LA, Grimm C, van Trotsenburg M, Nagele F. Role of the vaginally administered aromatase inhibitor anastrozole in women with rectovaginal endometriosis: a pilot study. Fertil Steril 2005; 84:1033.
  57. Fatemi HM, Al-Turki HA, Papanikolaou EG, et al. Successful treatment of an aggressive recurrent post-menopausal endometriosis with an aromatase inhibitor. Reprod Biomed Online 2005; 11:455.
  58. Soysal S, Soysal ME, Ozer S, et al. The effects of post-surgical administration of goserelin plus anastrozole compared to goserelin alone in patients with severe endometriosis: a prospective randomized trial. Hum Reprod 2004; 19:160.
  59. Nawathe A, Patwardhan S, Yates D, et al. Systematic review of the effects of aromatase inhibitors on pain associated with endometriosis. BJOG 2008; 115:818.
  60. Mousa NA, Bedaiwy MA, Casper RF. Aromatase inhibitors in the treatment of severe endometriosis. Obstet Gynecol 2007; 109:1421.
  61. Ferrero S, Camerini G, Seracchioli R, et al. Letrozole combined with norethisterone acetate compared with norethisterone acetate alone in the treatment of pain symptoms caused by endometriosis. Hum Reprod 2009; 24:3033.
  62. Zhu X, Hamilton KD, McNicol ED. Acupuncture for pain in endometriosis. Cochrane Database Syst Rev 2011; :CD007864.
  63. Xiang D, Situ Y, Liang X, et al. Ear acupuncture therapy for 37 cases of dysmenorrhea due to endometriosis. J Tradit Chin Med 2002; 22:282.
  64. Parazzini F, Chiaffarino F, Surace M, et al. Selected food intake and risk of endometriosis. Hum Reprod 2004; 19:1755.
  65. Cahill DJ. What is the optimal medical management of infertility and minor endometriosis? Analysis and future prospects. Hum Reprod 2002; 17:1135.
  66. Hughes E, Fedorkow D, Collins J, Vandekerckhove P. Ovulation suppression for endometriosis. Cochrane Database Syst Rev 2000; :CD000155.
  67. Benaglia L, Somigliana E, Vighi V, et al. Rate of severe ovarian damage following surgery for endometriomas. Hum Reprod 2010; 25:678.
  68. Fedele L, Bianchi S, Zanconato G, et al. Is rectovaginal endometriosis a progressive disease? Am J Obstet Gynecol 2004; 191:1539.
  69. Shaw RW. Treatment of endometriosis. Lancet 1992; 340:1267.
  70. Vercellini P, Crosignani PG, Somigliana E, et al. Medical treatment for rectovaginal endometriosis: what is the evidence? Hum Reprod 2009; 24:2504.
  71. Ferrero S, Camerini G, Ragni N, et al. Norethisterone acetate in the treatment of colorectal endometriosis: a pilot study. Hum Reprod 2010; 25:94.
  72. Vercellini P, Pietropaolo G, De Giorgi O, et al. Treatment of symptomatic rectovaginal endometriosis with an estrogen-progestogen combination versus low-dose norethindrone acetate. Fertil Steril 2005; 84:1375.
  73. Donnez J, Nisolle M, Gillerot S, et al. Rectovaginal septum adenomyotic nodules: a series of 500 cases. Br J Obstet Gynaecol 1997; 104:1014.
  74. Chapron C, Bourret A, Chopin N, et al. Surgery for bladder endometriosis: long-term results and concomitant management of associated posterior deep lesions. Hum Reprod 2010; 25:884.
  75. Busacca M, Chiaffarino F, Candiani M, et al. Determinants of long-term clinically detected recurrence rates of deep, ovarian, and pelvic endometriosis. Am J Obstet Gynecol 2006; 195:426.
  76. Vercellini P, Pietropaolo G, De Giorgi O, et al. Reproductive performance in infertile women with rectovaginal endometriosis: is surgery worthwhile? Am J Obstet Gynecol 2006; 195:1303.
  77. Darai E, Ackerman G, Bazot M, et al. Laparoscopic segmental colorectal resection for endometriosis: limits and complications. Surg Endosc 2007; 21:1572.
  78. Minelli L, Fanfani F, Fagotti A, et al. Laparoscopic colorectal resection for bowel endometriosis: feasibility, complications, and clinical outcome. Arch Surg 2009; 144:234.
  79. Daraï E, Bazot M, Rouzier R, et al. Outcome of laparoscopic colorectal resection for endometriosis. Curr Opin Obstet Gynecol 2007; 19:308.
  80. Dubernard G, Rouzier R, David-Montefiore E, et al. Urinary complications after surgery for posterior deep infiltrating endometriosis are related to the extent of dissection and to uterosacral ligaments resection. J Minim Invasive Gynecol 2008; 15:235.
  81. Koninckx PR, Timmermans B, Meuleman C, Penninckx F. Complications of CO2-laser endoscopic excision of deep endometriosis. Hum Reprod 1996; 11:2263.
  82. Roman H, Loisel C, Resch B, et al. Delayed functional outcomes associated with surgical management of deep rectovaginal endometriosis with rectal involvement: giving patients an informed choice. Hum Reprod 2010; 25:890.
  83. Practice bulletin no. 114: management of endometriosis. Obstet Gynecol 2010; 116:223.