Treating endometriosis: tailoring options to your situation

Hormonal therapy: slowing the disease and relieving pain

Hormonal treatment for endometriosis works by reducing or suppressing menstrual cycles. By limiting hormonal stimulation of the lesions, it reduces their inflammatory activity and associated pain. It relieves symptoms but does not eliminate existing lesions.

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First-line treatments

Hormonal contraceptives (such as continuous combined oral contraceptive pills or levonorgestrel-releasing intrauterine systems) are offered as a first-line approach. They reduce the frequency and intensity of periods and relieve most pelvic pain.

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Second-line treatments

Oral progestins, including dienogest, are indicated when first-line contraceptives are ineffective or contraindicated. In addition to their pain-relieving effects, they act directly on endometriosis lesions.

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Third-line treatments

GnRH analogues induce a temporary medical menopause by suppressing ovarian hormone production. While effective for severe pain, they cause side effects related to low estrogen levels (such as hot flashes and potential bone loss), which limits their long-term use. More recently available GnRH antagonists, which include integrated add-back therapy, offer a better tolerability profile by mitigating these side effects while maintaining pain relief.

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Surgery: when is it necessary and who should perform it?

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When is surgery considered?

Surgery is not a routine step in endometriosis management. It is considered in specific situations:

• Failure or insufficient relief of pain with medical treatment
• Large ovarian endometriomas affecting ovarian reserve
• Deep endometriosis with organ involvement (digestive, bladder, or ureteral)
• Infertility associated with endometriosis, depending on the results of fertility testing

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Conservative versus radical surgery: what is the difference?

The conservative surgery aims to remove lesions while preserving the uterus and ovaries. This is the preferred approach for women of childbearing age, particularly those planning a pregnancy. Laparoscopy is the standard access route for this type of procedure.

The radical surgery (total hysterectomy, with or without removal of the ovaries) is reserved for specific situations: women who are no longer planning a pregnancy and whose pain persists despite all available treatments. It is not offered as a first-line option.

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Deep endometriosis: a procedure to be entrusted to an expert team

Deep infiltrating endometriosis involving the rectum, bladder, or ureters requires a significantly complex surgical procedure. It involves a multidisciplinary team: a gynecological surgeon specializing in endometriosis, and a digestive surgeon and/or urologist, depending on the organs involved. The completeness of the surgical procedure and choosing the right time to operate are determining factors for long-term outcomes.

Before making a surgical decision, a second opinion from a specialized gynecological surgeon can help confirm the proposed strategy, assess whether the timing is appropriate, and ensure that the team has the required expertise for this procedure.

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Endometriosis and the desire for pregnancy: balancing surgery and fertility treatment

Endometriosis can affect fertility in various ways: by reducing ovarian reserve in the case of endometriomas, or by disrupting tubal patency or the uterine environment. However, it does not mean infertility is certain: many women with the condition conceive naturally or with minimal intervention.

When a pregnancy is desired and endometriosis is confirmed, standard medical management (hormonal contraceptive treatments) is suspended. The central question then becomes: is it better to operate first, or to start fertility treatment directly?

• ‍Surgery before fertility treatment or fertility treatment from the start? The answer depends on the type and location of the lesions. If large ovarian endometriomas are present, prior surgery may improve the ovarian response to hormonal stimulation. In the absence of endometriomas, particularly in cases of deep endometriosis without ovarian involvement, an assisted reproductive technology (ART) pathway (IVF or insemination) may be proposed directly, without the need for surgery. This trade-off is one of the most complex decisions in managing endometriosis and must be discussed with a specialist familiar with the patient's individual situation. ‍
• Oocyte cryopreservation Before ovarian surgery (removal of endometriomas), egg freezing may be considered to preserve ovarian function before the procedure affects the reserve. This option should be discussed with the medical team prior to any surgical decision.

Any decision regarding the management of infertility associated with endometriosis requires specialized medical advice, taking the entire clinical situation into account.

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