What are the most commonly prescribed medications for endometriosis?

What medications are indicated for the treatment of endometriosis and what are the recommendations?

Unfortunately, to date, there is no treatment that can cure endometriosis. 

The medical treatments available are only suspensive, meaning that when treatment is stopped, the disease resumes its progression.

The therapeutic strategy used is personalised and depends in particular on the age of the patient, the severity of her symptoms, the stage and extent of the lesions, the possible desire for pregnancy and the socio-professional repercussions of the disease.

Endometriosis is a chronic illness which is treated differently across the different stages of a woman's life.

In very young women, a possible desire for contraception must be balanced with pain management.

For slightly older women who potentially wish to have children, it is necessary to find a balance between a desire for pregnancy and pain control, bearing in mind that most of the proposed treatments are hormonal and therefore anti-conceptional.

Finally, at more advanced ages, it is necessary to take into account the occurrence of risk factors for hormone treatment intolerance.

What are the different drug treatments used in the management of pain associated with endometriosis lesions?

Anti-inflammatory drugs

The pain experienced by patients with endometriosis is linked to inflammation. Anti-inflammatory drugs are therefore indicated in this case to reduce local inflammation and alleviate pain. 

This is a first line strategy where non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are offered.

However, due to significant gastric and renal side effects, their long-term use is strongly discouraged. 

It is therefore recommended that they be administered at the minimum effective dose, that treatment not exceed 5 days and that it be discontinued as soon as the symptoms disappear.

To limit the occurrence of digestive problems, NSAIDs can be taken with a meal. However, in the case of acute pain, taking them on an empty stomach ensures a faster onset of action.

Ibuprofen is available without a prescription and can be taken during the week of menstruation at 400 mg per dose, not exceeding 1600 mg per day (1 dose every 6 hours).

Analgesics (painkillers)

Non-opioid painkillers such as paracetamol are often ineffective in relieving the pain caused by endometriosis lesions. 

Opioid painkillers, available only on prescription, such as tramadol, are more effective but should be used with caution and should not be overused. Tramadol, for example contains an opiate that can cause dependency, so it is only recommended when NSAIDS or paracetamol have been proven ineffective.

Hormone treatments

Endometriosis lesions are hormone-dependent and evolve according to the menstrual cycle. 

The aim of hormonal treatments is to reduce the endometriosis lesions, to reduce the impact and duration of menstrual periods or to stop periods all together. Hormone treatment makes it possible to avoid bleeding from the endometriosis lesions, which alleviates pain. 

In this class of treatment, the first line of treatment is continuous combined oral contraceptive pill (oestrogen and progesterone) or the insertion of a hormonal intrauterine device (IUD) or coil, which blocks menstruation. 

Oral contraceptives may also be administered intermittently if the woman does not experience pain during her period on the pill and if she has not undergone surgery for her endometriosis.

Women who have had surgery are typically only offered continuous contraception to limit the risk of painful recurrence and to improve their quality of life.

As a second line of treatment, there is also dienogest (Visabelle®), a specific progestative to be taken continuously that has been developed to treat endometriosis.

If these different treatments fail, GnRH analogues, modified versions of the naturally occurring hormone gonadotropin releasing hormonre (GnRH), can be prescribed with, oestrogen and/or progestin supplementation to avoid the side effects of stopping hormone production. This treatment results in artificial menopause.

Oral hormone treatments should ideally be taken at the same time every day.

Is it possible to consider an IUD before having children?

Yes, it is! Intrauterine devices (IUDs) can be used in adolescents and women and have a 5-year duration in the case of the hormonal IUD. It can be removed at any time if the patients wishes to become pregnant, for example, and can therefore be inserted without any problem in a woman who has never had a child.

It is recommended that a check-up be carried out within 3 months of insertion and then every year following.

Furthermore, the insertion of an IUD does not affect intimate life in any way and physical activity is not likely to displace it.

Does blocking menstruation affect fertility?

No! The effects of hormone treatments are reversible and ovulation will resume normally after stopping treatment, even for those taking it continuously. Delays in ovulation lasting a few months may occur but this is rare and reversible.

However, some types of lesions are insensitive to hormones and do not regress on hormone treatment. In this case, surgery may be proposed to remove the lesions.

How to start taking oral hormone contraceptives?

The first tablet of the pack should be taken on the first day of menstruation and then the treatment continues with one tablet every day at the same time. If the first dose is not linked to a menstrual period, it will take about 7 days for the contraceptive to take effect and it will be necessary to continue using barrier methods of contraception (condoms, diaphragms, spermicides, etc.) during this time.

If vomiting or diarrhoea occurs within 4 hours of taking the contraceptive, a second tablet should be taken.

To avoid forgetting to take the pill, it is advisable to combine taking the pill with a daily routine such as brushing your teeth or eating breakfast. Another solution is to set a daily alarm on your phone.

If you forget to take the pill, if less than 12 hours have passed, you should take the tablet as soon as possible and continue your pack as normal.

If you forget to take the pill and more than 12 hours have passed, you should follow the same procedure, but also use barrier birth control methods for 7 days.

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