Surgery for Endometriosis

The only absolute way to diagnose endometriosis is laparoscopy or keyhole surgery. You should only have this surgery done by a gynaecologist who is experienced in the diagnosis and treatment of endometriosis. Dr Lenore Ellett is one of these surgeons as she has done extra training in the disease. When Dr Ellett sees suspicious lesions of endometriosis she cuts them out and sends them to a pathologist. There is good Australian medical data which shows that cutting out endometriosis not only gives a diagnosis but can improve pain and fertility. Surgery for endometriosis should be done with keyhole surgery and not a laparotomy (big cut on the abdomen) as it leads to better recovery and less scar tissue.

Medication Mode of Action Instructions on use
NSAID – non steroidal anti inflammatory drugs inhibit cyclo-oxygenase, reduction in prostaglandin production. The resulting lower level of prostaglandin leads to less vigorous contractions of the uterus, and therefore, less discomfort. Start NSAIDs the day before menstruation is expected. Trial for 3 months before adding in another agent
Combined oral contraceptive pill Suppress ovulation, reduce growth of endometrial tissue, down regulate cell proliferation, increase apoptosis of ectopic endometrium Consider tri-cycling the OCP (skip placebo pills for 3 months)
Oral progestins Progestins inhibit endometriotic tissue growth by causing decidualization and atrophy, [estradiol]↓ due to inhibition of the hypothalamic-pituitary-ovarian axis Norethisterone acetate  5-15mg per day (primolutTM)
Injectable progestin eg depot medroxy progesterone acetate Inhibition of ovulation, decidualization and atrophy of endometrium and endometriosis deposits Depot provera is given as an injection every three months. Care should be taken in young women due to concern about bone mineral density
Progestogen implant Inhibition of ovulation, decidualization and atrophy of endometrium ImplanonTM is a subdermal rod which lasts for 3 years as a contraceptive agent. Unpredictable vaginal bleeding is a common side effect
Danazol Suppression of pituitary-ovarian axis Androgenic side effects can be extremely troublesome – hirsutism, acne, irreversible voice deepening
Aromatase inhibitors Aromatase converts androgens to estrogen. Aromatase inhibitors block the local biosynthesis of estrogen in the endometriotic lesions and lead to a decrease in symptoms. Aromatase inhibitors cause folliculogenesis (multiple cysts) so an OCP or gnRH analogue needs to also be prescribed. Bone mineral density is also negatively affected
Gonadotrophin releasing hormone (GnRH) analogues


GNRHa down regulate the hypothalamic-pituitary axis, leading to a hypoestrogenic state and improvement in symptoms of endometriosis Zoladex implants are given monthly for a maximum of 6 months. Bone mineral density is negatively affected so addback therapy with oral norethisterone acetate or hormone replacement therapy is recommended

Synarel nasal spray is another option

Levonorgestrel intrauterine system The LNG-IUS  delivers 20 µg /day causes atrophy of the endometrium which becomes atrophic and inactive, ovulation is usually not suppressed. Mirena IUD can be inserted in an outpatient setting or during a general anaesthetic, contraceptive effect lasts 5 years.