Hormonal treatment

Hormonal treatment of endometriosis

Endometriosis is a chronic condition whose activity is significantly influenced by female sex hormones, especially oestrogens. Hormonal treatment works by suppressing cyclical hormonal changes, often suppressing ovulation and menstruation, and reducing the activity of lesions. This can relieve pain, bleeding and other symptoms.

Hormonal treatment, however, does not remove endometriosis lesions. It helps keep the condition under control, but after stopping, symptoms may return. It is also not a treatment for infertility - it is not usually prescribed to women who are actively trying to conceive with the aim of increasing the chance of natural conception.

When is hormonal treatment appropriate?

• as first-line treatment for women with mild to moderate symptoms
• after surgery to delay potential disease recurrence
• for women who do not plan pregnancy in the near future
• as long-term maintenance treatment between pregnancies

Combined hormonal contraception

Pills containing oestrogen and progestin are most commonly the first-line treatment. They suppress ovulation, reduce oestrogen levels and significantly relieve menstrual pain and bleeding. They can be taken continuously - without a break - completely avoiding menstruation.

Advantages include availability, low cost and suitability for long-term use. Side effects are usually mild - nausea, breast tenderness, mood changes. Unsuitable for women with risk of blood clotting.

Progestins

Preparations containing only progestin (without oestrogen) have been used in the treatment of endometriosis since the 1950s. They suppress the growth of endometrial implants and cause their gradual atrophy. Approximately 3 out of 4 women (75%) experience significant pain relief with progestins.

Important: progestins are only effective with continuous daily use - taking them only in the second half of the cycle produces no effect. Side effects include acne, bloating, breakthrough bleeding, mood changes and weight gain - their intensity varies between different preparations and between individual women.

GnRH analogues

GnRH analogues (gonadotropin-releasing hormone) are powerful preparations that temporarily induce a menopause-like state - the ovaries stop producing oestrogen and endometriosis settles significantly.

Standard treatment duration is 3-6 months. A three-month course relieves pain as effectively as six months, but six months delays symptom recurrence longer. With concurrent add-back therapy, treatment can be extended.

GnRH analogues are more commonly used before planned IVF.

Add-back therapy

GnRH analogues cause menopause-like side effects - hot flushes, night sweats, vaginal dryness, headaches, mood changes, reduced libido. The most serious side effect is bone density loss - approximately 4-6% after a 6-month course, which mostly recovers within 18-24 months after treatment ends.

Add-back therapy - supplementation with a low dose of oestrogen, progestin or tibolone - significantly reduces these side effects without reducing GnRH efficacy. It enables repeated or continuous treatment courses for up to 2 years.

Important warning about GnRH

GnRH analogues should not be started before surgery for peritoneal (superficial) lesions - they reduce lesion visibility and complicate the surgeon's identification of them. They are also not suitable as a fertility treatment without assisted reproduction.

GnRH antagonists

A newer class of preparations - elagolix, relugolix - in tablet form with a similar effect to GnRH analogues but faster onset and the possibility of dose adjustment.

How to choose the right preparation?

The choice depends on several factors:

• Symptom intensity - severe pain or advanced endometriosis warrants stronger medications
• Side effect tolerance - each woman responds differently; it may be necessary to try and change preparations
• Duration of planned treatment - some preparations suit short-term, others long-term use
• Pregnancy planning - all hormonal treatment suppresses ovulation; treatment must be stopped in good time
• Health contraindications - blood clotting risk excludes combined contraception

What to do if treatment isn't working?

If hormonal treatment does not provide sufficient relief, it is important to tell your doctor. Options include:

• changing the preparation or dosage
• combining several methods
• adding physiotherapy or psychological support
• considering surgical treatment

Accepting pain is not a solution. If your current treatment is insufficient, book a consultation with us - we will be happy to assess your situation and suggest an appropriate approach.

Detailed information on hormonal preparations: endometriosis.org - Treatments.