Endometriosis

Topic Overview

What is endometriosis?

Endometriosis (say 'en-doh-mee-tree-OH-sus') is a problem many women have during their childbearing years. It means that a type of tissue that lines your uterus is also growing outside your uterus. This does not always cause symptoms, and it usually is not dangerous. But it can cause pain and other problems.

The clumps of tissue that grow outside your uterus are called implants. They usually grow on the ovaries, the fallopian tubes, the outer wall of the uterus, the intestines, or other organs in the belly. In rare cases, they spread to areas beyond the belly.

How does endometriosis cause problems?

Your uterus is lined with a type of tissue called endometrium (say 'en-doh-MEE-tree-um'). It is like a soft nest where a fertilized egg can grow. Each month, your body releases hormones that cause the endometrium to thicken and get ready for an egg. If you get pregnant, the fertilized egg attaches to the endometrium and starts to grow. If you do not get pregnant, the endometrium breaks down, and your body sheds it as blood. This is your menstrual period.

When you have endometriosis, the implants of tissue outside your uterus act just like the tissue lining your uterus. During your menstrual cycle, they get thicker, then break down and bleed. But the implants are outside your uterus, so the blood cannot flow out of your body. The implants can get irritated and painful. Sometimes they form scar tissue or fluid-filled sacs (cysts). Scar tissue may make it hard to get pregnant.

What causes endometriosis?

Experts do not know what causes endometrial tissue to grow outside your uterus. But they do know that the female hormone estrogen makes the problem worse. Women have high levels of estrogen during their childbearing years. It is during these years-usually from their teens into their 40s-that women have endometriosis. Estrogen levels drop when menstrual periods stop (menopause). Symptoms usually go away then.

What are the symptoms?

The most common symptoms are:

• Pain. Where it hurts depends on where the implants are growing. You may have pain in your lower belly, your rectum or vagina, or your lower back. You may have pain only before and during your periods or all the time. Some women have more pain during sex, when they have a bowel movement, or when their ovaries release an egg (ovulation).
• Abnormal bleeding. Some women have heavy periods, spotting or bleeding between periods, bleeding after sex, or blood in their urine or stool.
• Trouble getting pregnant (infertility). This is the only symptom some women have.

Endometriosis varies from woman to woman. Some women do not know that they have it until they go to see a doctor because they cannot get pregnant. Some have mild cramping that they think is normal for them. In other women, the pain and bleeding are so bad that they are not able to work or go to school.

How is endometriosis diagnosed?

Many different problems can cause painful or heavy periods. To find out if you have endometriosis, your doctor will:

• Ask questions about your symptoms, your periods, your past health, and your family history. Endometriosis sometimes runs in families.
• Do a pelvic exam. This may include checking both your vagina and rectum.

If it seems like you have endometriosis, your doctor may suggest that you try medicine for a few months. If you get better using medicine, you probably have endometriosis.

To find out if you have a cyst on an ovary, you might have an imaging test like an ultrasound, an MRI, or a CT scan. These tests show pictures of what is inside your belly.

The only way to be sure you have endometriosis is to have a type of surgery called laparoscopy (say 'lap-uh-ROS-cuh-pee'). During this surgery, the doctor puts a thin, lighted tube through a small cut in your belly. This lets the doctor see what is inside your belly. If the doctor finds implants, scar tissue, or cysts, he or she can remove them during the same surgery.

How is it treated?

There is no cure for endometriosis, but there are good treatments. You may need to try several treatments to find what works best for you. With any treatment, there is a chance that your symptoms could come back.

Treatment choices depend on whether you want to control pain or you want to get pregnant. For pain and bleeding, you can try medicines or surgery. If you want to get pregnant, you may need surgery to remove the implants.

Treatments for endometriosis include:

• Over-the-counter pain medicines like ibuprofen (such as Advil or Motrin) or naproxen (such as Aleve). These medicines are called anti-inflammatory drugs, or NSAIDs. They can reduce bleeding and pain.
• Birth control pills. They are the best treatment to control pain and shrink implants. Most women can use them safely for years. But you cannot use them if you want to get pregnant.
• Hormone therapy. This stops your periods and shrinks implants. But it can cause side effects, and pain may come back after treatment ends. Like birth control pills, hormone therapy will keep you from getting pregnant.
• Laparoscopy to remove implants and scar tissue. This may reduce pain, and it may also help you get pregnant.

As a last resort for severe pain, some women have their uterus and ovaries removed (hysterectomy and oophorectomy). If you have your ovaries taken out, your estrogen level will drop and your symptoms will probably go away. But you may have symptoms of menopause, and you will not be able to get pregnant.

If you are getting close to menopause, you may want to try to manage your symptoms with medicines rather than surgery. Endometriosis usually stops causing problems when you stop having periods.

What else should you think about?

If you are thinking about using medicines for pain, keep the following in mind:

• NSAIDs are not a good choice if there is a chance that you are or could soon become pregnant. They may increase the chance that you will have a miscarriage. Check with your doctor before using any over-the-counter medicine for more than a few days at a time.
• Hormone therapy can cause a range of side effects. Some are unpleasant, like those caused by menopause. Others are serious, like bone thinning (osteoporosis). To limit these problems, hormone therapy is only used for a few months at a time. Be sure to find out the side effects of any therapy you are thinking about.

Frequently Asked Questions

Health Tools

Health Tools help you make wise health decisions or take action to improve your health.

	Decision Points focus on key medical care decisions that are important to many health problems.
	Should I have a hysterectomy and oophorectomy to treat endometriosis?
	Should I use estrogen replacement therapy (ERT) after a hysterectomy and oophorectomy?
	Should I use hormone therapy to treat endometriosis?

Cause

The exact cause of endometriosis is not known. Possible explanations include the following:

• The immune system normally destroys any endometrial cells outside of the uterus. But women with endometriosis may have a problem with the immune system that may impair this process.¹
• Menstrual bleeding (which contains endometrial cells) is carried up through the fallopian tubes into the abdomen (retrograde menstruation). This happens with most women. But it may be worse if you have heavy menstrual bleeding or were born with an abnormal structure of the uterus, cervix, or vagina that blocks or slows menstrual flow.²
• Endometrial cells may be carried to other locations in the body by the blood or lymph fluid circulation.
• Endometrial cells may be moved to another area during surgery, such as an episiotomy after childbirth or a cesarean delivery.
• Cells in the abdomen and pelvis, which are closely related to the cells of the reproductive system, may change into endometrial cells.
• Endometrial cells may be deposited outside the uterus before birth.
• Sometimes, the tendency to develop endometriosis is passed down through families (genetic cause).²

Symptoms

Some women with endometriosis do not have symptoms. Other women have symptoms that range from mild to severe.

Endometriosis symptoms are often most severe just before and during the menstrual cycle and get better as the menstrual period is ending. But for some women, pain is ongoing and does not improve during the menstrual cycle.³ Ongoing pain is especially common in teens with endometriosis.

Symptoms may include:

• Pain, which can be:
  • Pelvic pain.
  • Severe menstrual cramps.
  • Low backache 1 or 2 days before the start of the menstrual period (or earlier), becoming less during the period.
  • Pain during sexual intercourse.
  • Rectal pain.
  • Pain during bowel movements.
• Infertility, which may be the only sign that you have endometriosis. Between 20% and 40% of women who are infertile have endometriosis.¹
• Abnormal bleeding. This can include:
  • Blood in the urine or stool.
  • Some vaginal bleeding before the start of the menstrual period (premenstrual spotting).
  • Vaginal bleeding after intercourse.

Endometrial growths (implants) that are large are not necessarily more painful. Instead, pain and bleeding are closely linked to an implant's location or how deeply it has grown.

Several other conditions, such as painful periods, adenomyosis, or noncancerous growths in the uterus called uterine fibroids, can cause symptoms that are similar to endometriosis.

What Happens

Endometriosis is usually a long-lasting (chronic) disease. Some women have no symptoms or problems. Others develop mild to severe symptoms or infertility. There is no way to predict whether endometriosis will get worse, will improve, or will stay the same until menopause.

Endometrial growths (implants) can develop on the ovaries or fallopian tubes, the outer surface of the uterus, the bowels, or other abdominal organs. In rare cases, it can affect other organs and structures in the body.

Endometriosis implants go through the same growing, breaking down, and bleeding that the uterine lining (endometrium) goes through with each menstrual cycle. This is why endometriosis pain may start as mild discomfort a few days before the menstrual period, and usually goes away by the time the period ends. But if an implant grows in a sensitive area, it can cause constant pain or pain during certain activities, such as sex, exercise, or bowel movements.

Endometriosis symptoms often get better during pregnancy, and they usually disappear after menopause. These are times when estrogen levels are low, which slows or stops endometriosis growth.³ For most women, endometriosis symptoms also improve with hormonal treatments that lower estrogen levels.

Ovarian cancer risk is higher in women with endometriosis.² This type of ovarian cancer is most commonly seen in women older than 60.

• Birth control pill use for 5 or more years lowers ovarian cancer risk.⁴
• Danazol, sometimes used to treat endometriosis, may increase ovarian cancer risk.⁵

Infertility and endometriosis

Between 20% and 40% of women who are infertile have endometriosis (some have more than one possible cause of infertility).¹ Experts do not fully understand how endometriosis causes infertility. Explanations include the following:⁶

• Scar tissue (adhesions) may form at the sites of implants and change the shape or function of the ovaries, fallopian tubes, or uterus. Scar tissue can:
  • Block the fallopian tubes, preventing or slowing the movement of eggs (ova) from the ovaries to the uterus.
  • Surround the ovaries, preventing eggs from moving to the fallopian tubes.
• The endometrial implants may change the chemical and hormonal makeup in the fluid that surrounds the organs in the abdominal cavity (peritoneal fluid). Such a change can:
  • Interfere with or prevent the release of eggs from the ovaries (ovulation). Some women with endometriosis do not ovulate.
  • Interfere with the fallopian tubes' ability to help an egg move toward the uterus.
  • Prevent a pregnancy in the uterus.
  • Change the menstrual cycle.

Infertility caused by endometriosis can sometimes be successfully treated with surgery, fertility drug treatment and insemination, in vitro fertilization, or a combination of these.

Ovarian endometrioma

A common complication of endometriosis is the development of a cyst on an ovary. This blood-filled growth is called an ovarian endometrioma, or an endometrial cyst. Endometriomas can be as small as 1 mm or more than 10 cm (3.9 in.) across.³

Ovarian endometriomas may not cause specific symptoms. The symptoms may be the same as those of endometriosis, since the endometrioma may not be the only site of endometriosis. Your health professional may be able to feel an endometrioma during a gynecologic exam. A large endometrioma is usually surgically removed.

What Increases Your Risk

Factors that raise your risk of developing endometriosis include:

• Being between puberty and menopause (around age 50). After estrogen levels drop at menopause, endometriosis risk disappears. In the past it was thought that women could only have endometriosis after many years of menstrual periods, but this is not true. Endometriosis has been found in girls before puberty and soon after their first menstrual period.
• Family history in a mother or sister (first-degree relative), which makes severe endometriosis more likely. This risk appears to be inherited through the mother.
• Menstrual cycles of less than 28 days.
• Menstrual flow of longer than 7 days.
• Menstruation that started before age 12.
• Fewer than two full-term pregnancies.³
• An abnormal structure of the uterus, cervix, or vagina (usually present from birth) that blocks or slows menstrual flow.

When To Call a Doctor

Call a health professional immediately if you develop sudden, severe pelvic pain.

Call a health professional to schedule an appointment if:

• Your periods have changed from relatively pain-free to painful.
• Pain interferes with your daily activities.
• You begin to have pain during intercourse.
• You have painful urination, blood in your urine, or an inability to control the flow of urine.
• You have blood in your stool or a significant, unexplained change in your bowel movements.
• You are not able to become pregnant after trying for 12 months.

Watchful Waiting

If you have mild pain during your period but have no other symptoms or concerns, you can wait through several menstrual cycles and discuss the pain with your health professional at your next regular visit. Home treatment may be all that you need to relieve mild pain.

Who To See

Health professionals who can evaluate endometriosis and help you manage the pain include:

• Family medicine physicians.
• Gynecologists.
• Internists.
• Nurse practitioners.
• Physician assistants.

If your case is complicated or your main problem is infertility, you may be referred to:

• A reproductive endocrinologist.
• A surgeon.

For diagnosis with laparoscopy or for surgical treatment, you may be referred to a gynecologist.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

To see whether your symptoms are caused by endometriosis, your health professional first will:

• Talk to you about your family and medical history, symptoms, and menstrual periods.
• Do a pelvic exam. This often includes checking both the vagina and rectum, where endometriosis sometimes forms.

If your exam, symptoms, and risk factors strongly suggest that you have endometriosis, your health professional may suggest that you first try nonsteroidal anti-inflammatory drug (NSAID) and/or hormone therapy before you have other tests. If treatment improves your symptoms after a few months, the diagnosis of endometriosis is more certain.

Possible ovarian endometrioma

If your health professional feels an abnormal mass on an ovary during the pelvic exam, you may have an endometriosis-filled cyst on an ovary (ovarian endometrioma) or other problems. The following tests can be used to evaluate a mass:

• A transvaginal ultrasound uses a probe that is inserted into the vagina. A computer processes the sounds waves to create a picture of the internal organs on a computer screen. Transvaginal ultrasound can detect endometriomas but not scar tissue. It is sometimes recommended before starting infertility treatment.¹
• A CT scan uses X-rays to produce a cross-sectional picture of internal organs.
• An MRI uses a magnetic field and pulses of radio-wave energy to provide pictures of internal organs. MRI can help a doctor tell the difference between an endometrioma and another type of ovarian growth.

Further testing

Laparoscopy is the most common surgical procedure used to diagnose and treat endometriosis. But laparoscopy is not always needed. It is usually done when infertility requires rapid treatment and probable surgery or when treatment has not relieved pain or infertility. If your doctor recommends a laparoscopy, it will be used to look for and possibly remove implants and scar tissue. During the same procedure, the doctor can:

• View the internal organs, looking for signs of endometriosis and other possible problems. This is the only way that endometriosis can be diagnosed with certainty. But a "no endometriosis" diagnosis is never certain-growths (implants) can be tiny or hidden from the doctor's view.
• Remove any visible endometriosis implants and scar tissue that may be causing pain or infertility. A doctor uses one or more techniques, including cutting and removing growths (excision) or destroying them with a laser beam or electric current (electrocautery). If an endometriosis cyst is found growing on an ovary (endometrioma), the cyst is likely to be removed.

Treatment Overview

Although there is no cure for endometriosis, treatment can help with pain and infertility. Treatment depends on how severe your symptoms are and whether you have future pregnancy plans. For pain only, any hormone therapy that lowers your body's estrogen levels will shrink endometriosis implants and may reduce pain. To become pregnant, surgery, infertility treatment, or both may help.

Endometriosis symptoms, no pregnancy plans

If you have endometrial pain or bleeding and no immediate plans to become pregnant, birth control hormones (patch, pills, or ring) or anti-inflammatories (NSAIDs) may be all that you need to control pain. Birth control hormones help shrink endometrial tissue and reduce pain for most women. They are also likely to keep endometriosis from getting worse.⁷ Anti-inflammatories reduce bleeding, inflammation, and pain. Most women can use these medicines safely for the long term with few side effects.

If you have more severe symptoms or if birth control hormones and NSAIDs do not work, you might try a stronger hormone therapy such as therapy with a gonadotropin-releasing hormone agonist (GnRH-a), progestin, a progestin intrauterine device (Mirena), danazol, or aromatase inhibitors. Some doctors will first do a laparoscopy to look for signs of endometriosis in the pelvis. But many think this is not needed unless there is a chance that you have another problem.⁸

Should I use hormone therapy to treat endometriosis?

If hormone therapy does not work or if growths are affecting other organs, surgery to remove endometrial growths and scar tissue is the next step. This can usually be done through one or more small incisions, using laparoscopy. Some studies suggest that using hormone therapy after surgery can make the pain-free period longer by preventing the growth of new or returning endometriosis.⁷ Surgery relieves pain for a year or two in most women, although about 20% of women report no improvement after surgery.⁹

In severe cases, removing the uterus and ovaries (hysterectomy and oophorectomy) is an option. This surgery causes early menopause. It is reserved for women with no pregnancy plans who have had little relief with other treatments. But up to 15% of women continue to have pain after this major surgery.¹⁰

Should I have a hysterectomy and oophorectomy to treat endometriosis?

Infertility treatment

If you are having trouble becoming pregnant, treatment decisions for endometriosis may be more complex. The treatment you and your doctor choose may depend on how bad your endometriosis is, your age, your health in general, and other factors. Options to improve your chances of pregnancy include:

• Intercourse during the most fertile days of each menstrual cycle. If your endometriosis is not very bad, this may be all you need to try.
• Laparoscopic surgery. Surgical removal of endometriosis and scar tissue can improve pain and your chance for pregnancy. This is especially true for women with mild to moderate endometriosis.¹¹
• Superovulation medicine (clomiphene or gonadotropins) and intrauterine insemination. These are often used to treat infertility in women.
• In vitro fertilization. If surgery does not lead to pregnancy, in vitro fertilization can help improve your chances.

Using hormone therapy for endometriosis will not help with infertility. Hormone therapy for endometriosis prevents pregnancy. But some studies of women with severe endometriosis have found that 6 months of GnRH-a treatment before in vitro fertilization improves the chances of conceiving a successful pregnancy.¹¹

What To Think About

Not all women with endometriosis have pain, and endometriosis does not always get worse over time. During pregnancy, endometriosis usually improves, as it does after menopause. If you have mild pain, have no plans for a future pregnancy, or are near menopause (around age 50), you may not feel a need for treatment. The decision is up to you.

Pain recurrence after hormone therapy

After treatment with any hormone therapy, endometriosis pain can, but does not always, return. Pain is more likely to return with more severe endometriosis.

Prevention

Endometriosis cannot be prevented. This is in part because the cause is poorly understood. But long-term use of birth control hormones (patch, pills, or ring) may prevent endometriosis from becoming worse.

Home Treatment

Home treatment may ease the pain and discomfort of endometriosis. You can supplement your medical treatment plan with one or more of the following measures.

• Take an anti-inflammatory drug (NSAID) such as ibuprofen (Motrin, Advil) on a regular schedule. Check with your health professional before using a nonprescription medicine for more than a few days. (If there is a chance that you are or could soon become pregnant, do not use an NSAID. NSAIDs have been linked to increased miscarriage risk, especially when used at the time of conception and when an NSAID is used for longer than a week.¹²)
  • Start taking the recommended dose as soon as your discomfort begins or the day before your menstrual period is scheduled to start.
  • Take the medicine in regularly scheduled doses. Taking the medicine only when your pain is 'really bad' is not as effective.
  • If one type of NSAID does not relieve your pain, try another type. Or try acetaminophen, such as Tylenol.
• Apply heat to your lower abdomen with a heating pad or hot water bottle, or take a warm bath. Heat improves blood flow and may relieve pelvic pain.
• Lie down and elevate your legs by placing a pillow under your knees. When lying on your side, bring your knees up to your chest to relieve back pressure.
• Use relaxation techniques and biofeedback. For more information, see the topic Stress Management.
• Exercise regularly. It improves blood flow, increases certain pain-relieving substances naturally made by the body (endorphins), and reduces pain.

Medications

Treatment with medicines does not cure endometriosis. Medicines are also generally not recommended if infertility from endometriosis is your main problem. But anti-inflammatory (NSAID) therapy can reduce pain and bleeding. Hormone therapy with birth control hormones, a gonadotropin-releasing hormone agonist (GnRH-a), progestin, or danazol can shrink endometriosis growths and reduce pain.

Birth control hormones and NSAID therapy are usually recommended first. Unlike other hormone therapies, they are least likely to cause serious side effects and can be a long-term treatment option.⁴

Medication Choices

• Anti-inflammatories (NSAIDs) reduce pain, inflammation, and bleeding from endometrial tissue.
• Birth control hormones (patch, pills, or ring) create hormone levels in the body that are similar to pregnancy. This stops monthly ovulation and the growing, shedding, and bleeding that makes endometriosis painful. Birth control hormones improve endometriosis pain for most women.⁷ And birth control hormones are the hormone therapy that is least likely to cause bad side effects. For this reason, many women can use them for years. Other hormone therapies can only be used for several months to 2 years. For more general information on birth control hormones, see Birth control pill, patch, or ring.
• Gonadotropin-releasing hormone agonist (GnRH-a) therapy lowers estrogen, triggering a menopause-like state. This shrinks implants and reduces pain for most women. This relief usually lasts for 6 to 12 months after ending GnRH-a therapy.⁸
• Progestin (pills or Depo-Provera shot) creates progestin levels in the body that are similar to pregnancy. This stops ovulation and lowers estrogen, shrinking endometriosis growths and reducing pain for most women.
• Danazol therapy lowers estrogen levels and raises androgen levels, triggering a menopause-like state. This shrinks endometriosis implants and reduces pain for most women. This relief usually lasts for 6 to 12 months after treatment. But danazol side effects can be significant.
• Aromatase inhibitors stop estrogen production. In small studies, aromatase inhibitors have been shown to reduce pain and the chance of endometriosis growths coming back. Aromatase inhibitors may help women with endometriosis who have not had relief with hormonal treatments. Aromatase inhibitors are used in combination with a hormonal treatment (such as birth control hormones or progestin). Long-term use of aromatase inhibitors may cause bone loss. More research needs to be done before it is known how well this treatment works and what the side effects are.¹³

Should I use hormone therapy to treat endometriosis?

Treatment with medicine does not restore fertility. In fact, hormone therapy prevents or endangers pregnancy. NSAIDs have been linked to increased miscarriage risk, especially at the time of conception and when an NSAID is used for longer than a week.¹²

What To Think About

Ovarian cancer risk is higher in women who have endometriosis.² Using birth control hormones for 5 or more years lowers this risk.⁴ Danazol may increase ovarian cancer risk.⁵

All hormone therapies for endometriosis can cause side effects and pose certain health risks. Some cause especially unpleasant side effects. Before starting a medicine or hormone therapy, review its possible side effects. If they sound less difficult than your endometriosis symptoms, discuss the therapy with your health professional.

GnRH-a, high-dose progestin, and aromatase inhibitors cause bone thinning. The GnRH-a effect is managed by also taking a small amount of hormone or other medicine (add-back therapy) and limiting GnRH-a use to 6 months. The progestin effect is slower. It takes 2 years of use to cause bone-thinning problems.¹⁴ After therapy, the bones regain most or all of their density.

Some studies of women with severe endometriosis who are infertile have found that 6 months of GnRH-a therapy before in vitro fertilization improves the chances of conceiving a successful pregnancy.¹⁵

Some studies suggest that using hormone therapy after surgery can make the pain-free period longer by preventing growth of new or returning endometriosis.⁷

Pain recurrence after hormone therapy

After treatment with any hormone therapy, endometriosis pain may return:¹

• Per year, up to 20% of all women treated will have pain that returns after hormone treatment.
• About 37% of women who use hormone therapy for mild endometriosis have pain 5 years later.
• About 74% of women who use hormone therapy for severe endometriosis have pain 5 years later.

If you use a GnRH-a or progestin to treat returning pain, it is likely that you will have pain relief much like you did the first time.¹

Surgery

Although surgery does not cure endometriosis, it does offer short-term results for most women and long-term relief for a few.

• Pain. Removing endometriosis growths (implants) and scar tissue relieves pain for most women. Between 70% and 100% of women report pain relief in the first months after surgery.¹ However, about 45% of women have symptoms that return within the first year after surgery.¹⁰ This number increases over time.¹
• Infertility. Removing moderate to severe endometriosis may improve your chances for pregnancy.¹⁵
• Removing the uterus and ovaries (hysterectomy and oophorectomy) is considered a last-resort measure to relieve endometriosis pain. But pain does return for up to 15% of women.¹⁰ You cannot ever become pregnant after this surgery.

Surgery is generally recommended for endometriosis when:

• Treatment with hormone therapy has not controlled symptoms, and symptoms interfere with daily living.
• Endometrial implants or scar tissue (adhesions) interferes with the functions of other abdominal organs.
• Endometriosis causes infertility.

Surgery Choices

• Laparoscopy is the most common procedure used to diagnose and treat endometriosis. If your doctor recommends a laparoscopy, it will be used to look for and possibly to remove or destroy implants and scar tissue. During the same procedure, the doctor can:
  • Examine the internal organs for signs of endometriosis and other possible problems. This is the only way that endometriosis can be diagnosed with certainty. But a "no endometriosis" diagnosis is never certain-growths (implants) can be tiny or hidden from the surgeon's view.
  • Remove any visible endometriosis implants and scar tissue that may be causing pain or infertility. A surgeon uses one or more techniques, including cutting and removing the growths (excision) or destroying them with a laser beam or an electric current (electrocautery). If the doctor finds an endometriosis cyst on an ovary (endometrioma), he or she will likely remove the cyst.
• Hysterectomy with oophorectomy offers the chance of long-term pain relief for women who have no future childbearing plans. But hysterectomy with oophorectomy is a major surgery that has risks of complications from the surgery and anesthesia. After having your ovaries removed, low-estrogen side effects can be more sudden and severe than low-estrogen symptoms at natural menopause. And, when you start menopause early, your risk of future osteoporosis increases unless you take measures to protect your bones. Talk to your health professional about whether estrogen replacement therapy or nonhormonal treatment (bisphosphonates) might be best for you.

Should I have a hysterectomy with oophorectomy to treat endometriosis?

Should I use estrogen replacement therapy after having a hysterectomy or oophorectomy?

What To Think About

Women who do not become pregnant after surgery can consider trying fertility drugs with insemination or in vitro fertilization. For more information, see the topic Fertility Problems.

Some studies suggest that using hormone therapy after surgery can make the pain-free period longer by preventing the growth of new or returning endometriosis.⁷

When laparoscopy may not be needed

Surgery is the only way to be sure that you have endometriosis. Usually, this can be done with a tiny viewing instrument that is inserted through a small incision (laparoscopy). But laparoscopy is not always needed. Doctors commonly try anti-inflammatory and/or hormonal treatment for suspected endometriosis. If this works, endometriosis is a more likely diagnosis.

Endometriosis symptoms will stop naturally after you reach menopause. If you are nearing age 50, controlling symptoms with home treatment and hormone therapy until you reach menopause may be a more reasonable choice for you than surgery. But if scar tissue is causing pain, hormone therapy will not be effective.

Other Treatment

To help relieve the stress and pain of endometriosis, you can consider using complementary and alternative treatments. Researchers have not yet looked at these therapies as endometriosis treatments. But the following have proven benefits for treating other conditions:

• Acupuncture and acupressure are used to relieve pain and to help treat some health conditions, including asthma and osteoarthritis.¹⁶
• Meditation is used to lower stress and relieve pain and to help treat some health conditions, including high blood pressure.

Other Places To Get Help

Organizations

Related Information

• Fertility Problems
• Hysterectomy
• Stress Management

References

Citations

1. Speroff L, Fritz MA (2005). Endometriosis. In Clinical Gynecologic Endocrinology and Infertility, 7th ed., pp. 1103-1133. Philadelphia: Lippincott Williams and Wilkins.

2. Guidice LC, Kao LC (2004). Endometriosis. Lancet, 364(9447): 1789-1799.

3. Mishell DR Jr, et al. (2001). Endometriosis and adenomyosis. In MA Stenchever et al., eds., Comprehensive Gynecology, 4th ed., pp. 531-564. St. Louis: Mosby.

4. Modugno F, et al. (2004). Oral contraceptive use, reproductive history, and risk of epithelial ovarian cancer in women with and without endometriosis. American Journal of Obstetrics and Gynecology, 191(3): 733-740.

5. Cottreau CM, et al. (2003). Endometriosis and its treatment with danazol or lupron in relation to ovarian cancer. Clinical Cancer Research, 9(14): 5142-5144.

6. Barbieri RL (2002). Endometriosis. In DC Dale, DD Federman, eds., Scientific American Medicine, section 16, chap. 10. New York: WebMD.

7. Johnson N, Farquhar C (2006). Endometriosis, search date April 2006. Online version of Clinical Evidence (15).

8. Winkel CA (2003). Evaluation and management of women with endometriosis. Obstetrics and Gynecology, 102(2): 397-408.

9. Abbott JA, et al. (2004). Laparoscopic excision of endometriosis: A randomized, placebo-controlled trial. Fertility and Sterility, 82(4): 878-884.

10. American College of Obstetricians and Gynecologists (1999). Medical management of endometriosis. ACOG Practice Bulletin No. 11. Obstetrics and Gynecology, 94(6): 1-14.

11. American Society for Reproductive Medicine (2006). Endometriosis and infertility. Fertility and Sterility, 86(Suppl 4): S156-S160.

12. Li D, et al. (2003). Exposure to non-steroidal anti-inflammatory drugs during pregnancy and risk of miscarriage: Population-based cohort study. BMJ, 327(7411): 368-372.

13. Attar E, Bulun S (2006). Aromatase inhibitors: The next generation of therapeutics for endometriosis? Fertility and Sterility, 85(5): 1307-1318.

14. U.S. Food and Drug Administration (2004). Black box warning added concerning long-term use of Depo-Provera contraceptive injection. FDA Talk Paper No. T04-50. Available online: http://www.fda.gov/bbs/topics/ANSWERS/2004/ANS01325.html.

15. American Society for Reproductive Medicine (2004). Endometriosis and infertility. Fertility and Sterility, 82(1): S40-S45.

16. Acupuncture. NIH Consensus Statement, vol. 15, no. 5 (1997 November 3-5). Available online: http://consensus.nih.gov/1997/1997Acupuncture107html.htm.

Other Works Consulted

• American Society for Reproductive Medicine (2006). Treatment of pelvic pain associated with endometriosis. Fertility and Sterility, 84(Suppl 4): S18-S27.

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