What Medications are Recommended for Endometriosis?
Dr. Kate Dudek • November 27, 2022 • 5 min read
Medication for endometriosis, the most common symptom of endometriosis is pain, with up to 80% of patients complaining of period pain and up to 50% experiencing chronic pelvic pain. Aside from the physical discomfort and day-to-day limitations that long-term, chronic pain causes, it can also massively impact a patient’s quality of life, potentially leading to psychological conditions including anxiety and depression. The anxiety can be exacerbated in those patients who experience heavy periods every month, which causes additional discomfort and worry.
Painkillers
The first line approach for managing the symptoms of endometriosis are over-the-counter painkillers. Non-steroidal anti-inflammatories (NSAIDs), such as ibuprofen, partly function by inhibiting the production of prostaglandins. Prostaglandins cause the uterus to contract during menstruation and this contributes to the period pain experienced by patients with endometriosis. Reducing the levels of prostaglandins will reduce the painful contractions. Codeine-based medications and paracetamol-containing products are other options for pain relief.
Hormone treatment
If painkillers do not provide sufficient relief from the symptoms of endometriosis there is the option of hormonal treatment. This is not a suitable option for those who are seeking help for infertility. The endometrial deposits that develop outside the uterus, and are characteristic of the condition, form in response to the hormone oestrogen. Hormonal therapy aims to block or reduce the production of oestrogen.
Frequently prescribed hormonal therapies include the combined contraceptive pill, progesterone pills and gonadotrophin releasing hormone (GnRH) analogues:
- The combined pill contains oestrogen and progesterone; it prevents ovulation and makes periods lighter and less painful.
- Progesterone suppresses the growth of endometrial tissue, reducing inflammation and pain.
- GnRH analogues block oestrogen production, causing the endometrial tissue to shrink and become inactive.
These drugs place the body into a temporary menopausal state, and long term use may require further medication to combat menopause-associated symptoms, such as hot flushes and bone density loss.
Alternative options
Medication is just one option for the treatment of endometriosis. If symptoms persist, another option to consider is surgery.
A fully personalised treatment approach is recommended for each patient, taking into account their age, symptoms, fertility status and family situation.
Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and menopause.
Get in touch if you have any questions about this article or any aspect of women’s health. We’re here for you.
Sources:
- Bulletti, C, et al. “Endometriosis and Infertility.” Journal of Assisted Reproduction and Genetics, vol. 27, no. 8, 25 June 2010, pp. 441–447., doi: 10.1007/s10815-010-9436-1.
- Endometriosis Treatment. Endometriosis UK, www.endometriosis-uk.org/endometriosis-treatment.
- Endometriosis. Mayo Clinic, 24 July 2018, https://www.mayoclinic.org/diseases-conditions/endometriosis/diagnosis-treatment/drc-20354661.
- Treatment: Endometriosis. NHS, www.nhs.uk/conditions/endometriosis/treatment/. Page last reviewed: 18/01/2019.
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I Have PCOS; Should I Take Metformin?
* [PCOS](https://nabtahealth.com/glossary/pcos/) is sometimes treated with metformin, a drug for [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/). * 60-70% of women with [PCOS](https://nabtahealth.com/glossary/pcos/) are insulin resistant which is why metformin may be prescribed. * Clinical studies exploring metformin and [PCOS](https://nabtahealth.com/glossary/pcos/) symptoms have been small and inconsistent, but there is some evidence metformin increases [ovulation](https://nabtahealth.com/glossary/ovulation/) rate in women with [PCOS](https://nabtahealth.com/glossary/pcos/) when compared to treatment with a placebo. * Other studies have found that there is no consistent evidence that metformin improves the signs of hyperandrogegism (such as hairiness from excess male hormones). * However, metformin should not be completely discounted as an option for the management of [PCOS](https://nabtahealth.com/glossary/pcos/) [Metformin](https://nabtahealth.com/what-is-metformin/) is the first line treatment approach for type 2 diabetes mellitus (T2DM). It works by improving the way in which the body responds to insulin, preventing blood sugar levels from getting too high. Metformin is not licensed for the treatment of [](https://nabtahealth.com/what-is-pcos/)[PCOS](https://nabtahealth.com/glossary/pcos/), but as many women with the condition are [insulin resistant](https://nabtahealth.com/treating-the-associated-symptoms-of-pcos/), it is often prescribed ‘off label’ to help manage the symptoms. This article aims to address some questions regarding the use of metformin in the management of [PCOS](https://nabtahealth.com/glossary/pcos/). Is there justification in its use? Can it help to improve the symptoms of the condition, or are there alternative options that will be more effective? Will there ever be a time when metformin is prescribed as standard for all women with [PCOS](https://nabtahealth.com/glossary/pcos/) and to treat [PCOS](https://nabtahealth.com/glossary/pcos/) side effects? #### **Why metformin and [PCOS](https://nabtahealth.com/glossary/pcos/)?** Metformin is safe and cost effective, hence it’s widespread use in the management of T2DM. [Insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) is not one of the three diagnostic criteria used in defining [PCOS](https://nabtahealth.com/glossary/pcos/), however it is recognised as a common feature. In fact, 60-70% of women with [PCOS](https://nabtahealth.com/glossary/pcos/) will be insulin resistant and it is thought that the higher than normal levels of insulin contribute to many of the phenotypic traits of the condition. Thus, it makes sense that treating the [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/) might help to alleviate other [PCOS](https://nabtahealth.com/glossary/pcos/) side effects, for example regulating the menstrual cycle and improving signs of unwanted hair growth and acne. #### **What does the science say about [PCOS](https://nabtahealth.com/glossary/pcos/) and metformin?** Unfortunately metformin has not turned out to be the wonder drug that some anticipated. The clinical studies to date have largely been small in sample size and results have been inconsistent. In 2017, the American Society for Reproductive Medicine published guidelines on the use of metformin for the treatment of [infertility](https://nabtahealth.com/glossary/infertility/) in women with [PCOS](https://nabtahealth.com/glossary/pcos/). They based these guidelines on the results of a comprehensive literature review. The main conclusions reached were: * There is some evidence that metformin increases [ovulation](https://nabtahealth.com/glossary/ovulation/) rate in women with [PCOS](https://nabtahealth.com/glossary/pcos/) when compared to treatment with a placebo. **However:** * Clomiphene citrate is more effective at inducing [ovulation](https://nabtahealth.com/glossary/ovulation/) than metformin. * Metformin plus clomiphene citrate is more effective than metformin alone. * There is insufficient data on pregnancy and live birth rates following metformin treatment. Thus, the longer term overall reproductive benefit cannot currently be established. **Furthermore:** * There is insufficient evidence to recommend metformin as an option to [reduce the risk of](https://nabtahealth.com/pcos-and-pregnancy/) [miscarriage](https://nabtahealth.com/glossary/miscarriage/) in women with [PCOS](https://nabtahealth.com/glossary/pcos/). * Preliminary work suggesting that preventative treatment with metformin reduces the risk of [](https://nabtahealth.com/gestational-diabetes-8-things-you-should-know/)[gestational diabetes](https://nabtahealth.com/glossary/gestational-diabetes/) has not been replicated in newer studies. The final conclusion reached by the Society was that they would not recommend metformin as the first line treatment approach for [ovulation](https://nabtahealth.com/glossary/ovulation/) induction. Medications such as clomiphene citrate, known to be an [ovulation](https://nabtahealth.com/glossary/ovulation/) inducer, are generally more effective than metformin for women who are experiencing [PCOS](https://nabtahealth.com/glossary/pcos/)\-related fertility issues. In addition to these findings, other studies have found that there is no consistent evidence that metformin improves the signs of [](https://nabtahealth.com/masculine-hormones-in-women/)[hyperandrogenism](https://nabtahealth.com/glossary/hyperandrogenism/). #### **The outlook for metformin as a [PCOS](https://nabtahealth.com/glossary/pcos/) treatment** Metformin should not be completely discounted as an option for the management of [PCOS](https://nabtahealth.com/glossary/pcos/). Whilst less effective than other options, metformin has been shown to restore [ovulation](https://nabtahealth.com/glossary/ovulation/) in some women with [PCOS](https://nabtahealth.com/glossary/pcos/). For women with [PCOS](https://nabtahealth.com/glossary/pcos/) clomiphene citrate is commonly used to induce [ovulation](https://nabtahealth.com/glossary/ovulation/), however, not all women respond to treatment with this drug. For the women that do not respond, it is possible that combination therapy with metformin may be more successful at inducing [ovulation](https://nabtahealth.com/glossary/ovulation/). However, the work on this to date is limited. There is a need for longer term studies on metformin, as most studies have only explored short course treatment approaches. [PCOS](https://nabtahealth.com/glossary/pcos/) varies considerably from woman to woman. The presenting symptoms differ in both type and severity, which is why [diagnosing it can be so challenging](https://nabtahealth.com/problems-with-traditional-diagnosis-of-pcos/). Women with [PCOS](https://nabtahealth.com/glossary/pcos/) are prone to other conditions such as obesity and [insulin resistance](https://nabtahealth.com/glossary/insulin-resistance/); they are also at greater risk of developing T2DM and [endometrial cancer](https://nabtahealth.com/a-guide-to-endometrial-cancer/). Whether metformin can be given prophylactically to reduce these risks remains unclear and once again highlights the need for longer-term studies with extensive follow-up periods. #### Will metformin be prescribed as standard to all women that receive a diagnosis of [PCOS](https://nabtahealth.com/glossary/pcos/)? Unlikely. A more valuable course of action would be for doctors to better understand the various [PCOS](https://nabtahealth.com/glossary/pcos/) phenotypes and thus, take a more individualised approach to treatment, deciding which of their patients could genuinely benefit from treatment with the drug. As a final note, the value of [lifestyle modifications](https://nabtahealth.com/is-it-possible-to-reverse-pcos/) should not be understated. Adopting lifestyle changes and losing weight has proven to be, by far, the best approach for managing the symptoms of [PCOS](https://nabtahealth.com/glossary/pcos/). It is also the most effective way for women with [PCOS](https://nabtahealth.com/glossary/pcos/) to reduce their risk of developing T2DM. Medication should remain a contingency strategy for use in those who do respond adequately to lifestyle alterations. Nabta is reshaping women’s healthcare. We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#a0d9c1ccccc1e0cec1c2d4c1c8c5c1ccd4c88ec3cfcd) if you have any questions about this article or any aspect of women’s health. We’re here for you. **Sources:** * Lashen, Hany. “Review: Role of Metformin in the Management of Polycystic Ovary Syndrome.” Therapeutic Advances in Endocrinology and [Metabolism](https://nabtahealth.com/glossary/metabolism/), vol. 1, no. 3, June 2010, pp. 117–128., doi:10.1177/2042018810380215. * Practice Committee of the American Society for Reproductive Medicine (Penzias, Alan, et al.) “Role of Metformin for [Ovulation](https://nabtahealth.com/glossary/ovulation/) Induction in Infertile Patients with Polycystic Ovary Syndrome ([PCOS](https://nabtahealth.com/glossary/pcos/)): a Guideline.” Fertility and Sterility, vol. 108, no. 3, Sept. 2017, pp. 426–441., doi:10.1016/j.fertnstert.2017.06.026. * “Summary of Possible Benefits and Harms: Information for the Public: Polycystic Ovary Syndrome: Metformin in Women Not Planning Pregnancy: Advice.” NICE, Feb. 2013, [www.nice.org.uk/advice/esuom6/ifp/chapter/Summary-of-possible-benefits-and-harms](http://www.nice.org.uk/advice/esuom6/ifp/chapter/Summary-of-possible-benefits-and-harms). * “Treatment. Polycystic Ovary Syndrome .” NHS Choices, NHS, [www.nhs.uk/conditions/polycystic-ovary-syndrome-](http://www.nhs.uk/conditions/polycystic-ovary-syndrome-pcos/treatment/)[pcos](https://nabtahealth.com/glossary/pcos/)/treatment/. * Yarandi, Razieh Bidhendi, et al. “Metformin Therapy before Conception versus throughout the Pregnancy and Risk of [Gestational Diabetes](https://nabtahealth.com/glossary/gestational-diabetes/) Mellitus in Women with Polycystic Ovary Syndrome: a Systemic Review, Meta-Analysis and Meta-Regression.” Diabetology & Metabolic Syndrome, vol. 11, no. 1, 23 July 2019, doi:10.1186/s13098-019-0453-7. * Zhou, Joseph, et al. “Metformin: An Old Drug with New Applications.” International Journal of Molecular Sciences, vol. 19, no. 10, 21 Sept. 2018, p. 2863., doi:10.3390/ijms19102863.
How Often Should I see a Doctor for Endometriosis?
There is no definitive rule with regards to how often you should see a doctor if you have [endometriosis](https://nabtahealth.com/glossary/endometriosis/). The main thing is to find a _sympathetic doctor_ who will take the time to listen to any concerns you might have. [Endometriosis](https://nabtahealth.com/glossary/endometriosis/) can be [difficult to diagnose](https://nabtahealth.com/how-is-endometriosis-diagnosed/) and often the [symptoms](../the-symptoms-of-endometriosis) will closely resemble those of other conditions, such as [irritable bowel syndrome](https://nabtahealth.com/glossary/irritable-bowel-syndrome/) ([IBS](https://www.niddk.nih.gov/health-information/digestive-diseases/irritable-bowel-syndrome)). For this reason you may initially be referred to a [gastroenterologist](https://nabtahealth.com/glossary/gastroenterologist/) rather than a [](https://nabtahealth.com/articles/top-10-gynaecologists/)[gynaecologist](https://nabtahealth.com/glossary/gynaecologist/). In fact, even once diagnosed, the best approach may well be to consult a multidisciplinary team of experts, depending on the specific symptoms you are experiencing. #### Looking after your emotional health It is also important to consider that [endometriosis](https://nabtahealth.com/glossary/endometriosis/) can have a large impact on your emotional wellbeing, and thus you need to manage more than just the physical symptoms of the condition. Chronic pain can be psychologically draining, as can putting on a ‘brave face’ in front of friends and family. It is not unusual for [](https://nabtahealth.com/articles/what-medications-are-recommended-for-endometriosis/)[endometriosis](https://nabtahealth.com/glossary/endometriosis/) patients to report feeling isolated and alone and the condition has a strong association with depression. It is important to consult your doctor before these feelings start to overwhelm you. Your doctor should also be able to put you in contact with local support groups, where you will have the opportunity to talk to other women who are in the same position. #### Personalised treatment approach The wide ranging clinical presentation of [](https://nabtahealth.com/articles/how-is-endometriosis-diagnosed/)[endometriosis](https://nabtahealth.com/glossary/endometriosis/) means that every patient ideally needs to have a [personalised treatment plan](https://nabtahealth.com/), tailored to their own requirements. This can take time to optimise, so in the early days after diagnosis, it might be necessary to see the doctor on a regular basis. As symptoms improve, the frequency of visits should subside. Nabta is reshaping [women’s healthcare](https://nabtahealth.com). We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Try Nabta’s [Cycle Monitoring with OvuSense](https://nabtahealth.com/product/cycle-monitoring-with-ovusense/) and understand your cycle and health. Get in [touch](/cdn-cgi/l/email-protection#dca5bdb0b0bd9cb2bdbea8bdb4b9bdb0a8b4f2bfb3b1) if you have any questions about this article or any aspect of women’s health. We’re here for you. **Sources:** * _[Endometriosis](https://nabtahealth.com/glossary/endometriosis/) FAQs_. [Endometriosis](https://nabtahealth.com/glossary/endometriosis/) UK, [https://www.](https://www.endometriosis-uk.org/endometriosis-faqs)[endometriosis](https://nabtahealth.com/glossary/endometriosis/)\-uk.org/[endometriosis](https://nabtahealth.com/glossary/endometriosis/)\-faqs. * _Overview: [Endometriosis](https://nabtahealth.com/glossary/endometriosis/)_. NHS, [www.nhs.uk/conditions/](http://www.nhs.uk/conditions/endometriosis/)[endometriosis](https://nabtahealth.com/glossary/endometriosis/)/. Page last reviewed: 18/01/2019.
How is Endometriosis Diagnosed?
[](https://nabtahealth.com/what-is-endometriosis/)[Endometriosis](https://nabtahealth.com/glossary/endometriosis/) Diagnosis can be challenging because the [symptoms](../the-symptoms-of-endometriosis) are often difficult to distinguish from [irritable bowel syndrome](https://nabtahealth.com/glossary/irritable-bowel-syndrome/); symptoms such as diarrhea, [constipation](https://nabtahealth.com/glossary/constipation/) and abdominal cramping are frequently seen with either or both conditions. Other symptoms, such as heavy and painful periods, and migraines, may be dismissed as normal ‘[monthly women problems](https://nabtahealth.com/articles/how-can-i-regulate-my-periods/)’. As well as regularly presenting with symptoms that are indistinguishable from other conditions, there is also a great deal of variability from patient to patient, further complicating diagnosis. 20-25% of _women with [endometriosis](https://nabtahealth.com/glossary/endometriosis/)_ are [asymptomatic](https://nabtahealth.com/glossary/asymptomatic/), suggesting that the cited incidence rate of 6-10% of the female population having [endometriosis](https://nabtahealth.com/glossary/endometriosis/), is probably an under-estimation. Due to the inefficiency of the diagnostic tools currently in place, it very often takes years to diagnose a woman with [endometriosis](https://nabtahealth.com/glossary/endometriosis/). Diagnostic techniques --------------------- If you suspect you have [endometriosis](https://nabtahealth.com/glossary/endometriosis/), the first thing your doctor will do is examine your tummy and pelvis. They will feel for any abnormalities, such as cysts around your [](https://nabtahealth.com/articles/do-polycystic-ovaries-equal-pcos/)[ovaries](https://nabtahealth.com/glossary/ovaries/). Of course there are other conditions that cause [cysts](../are-ovarian-cysts-the-same-thing-as-pcos) to form on the [ovaries](https://nabtahealth.com/glossary/ovaries/), so this alone is not sufficient to diagnose [endometriosis](https://nabtahealth.com/glossary/endometriosis/). The current ‘[gold](https://nabtahealth.com/glossary/gold/) standard’ test for [endometriosis](https://nabtahealth.com/glossary/endometriosis/) is to perform a [](../what-is-a-laparoscopy)[laparoscopy](https://nabtahealth.com/glossary/laparoscopy/). This is a procedure performed under general anaesthetic, where a small tube is passed through a cut in your abdomen. The surgeon will use a camera to view any abnormal tissue. Ideally, at least a single [biopsy](https://nabtahealth.com/glossary/biopsy/) will be taken at the same time, for further histological analysis. Histological diagnosis is usually accurate and, if this supports a positive diagnosis, an appropriate treatment plan can be implemented. Alternative, non-invasive tests, such as [transvaginal ultrasound](https://nabtahealth.com/glossary/transvaginal-ultrasound/) and MRI scans have been shown to have very good accuracy at diagnosing deep [endometriosis](https://nabtahealth.com/glossary/endometriosis/), particularly when used in combination. Accuracy of diagnosis can be as high as 95%, which matches the level seen with [](https://nabtahealth.com/articles/what-is-a-laparoscopy/)[laparoscopy](https://nabtahealth.com/glossary/laparoscopy/). Deep [endometriosis](https://nabtahealth.com/glossary/endometriosis/) is thought to affect up to 20% of patients. The main advantage to these imaging techniques is that they are less invasive than the current tests of choice and their popularity in the clinical setting is likely to continue to grow. The future for [endometriosis](https://nabtahealth.com/glossary/endometriosis/) diagnosis ----------------------------------------------------------------------------------------- An understudied area of research for the diagnosis of [endometriosis](https://nabtahealth.com/glossary/endometriosis/) is the identification of serum biomarkers of the condition. Levels of a protein, CA-125, are often raised in patients with [endometriosis](https://nabtahealth.com/glossary/endometriosis/). However, as a general marker of [](https://nabtahealth.com/product/vitamin-d-and-inflammation-test/)[inflammation](https://nabtahealth.com/glossary/inflammation/), it is not specific to [endometriosis](https://nabtahealth.com/glossary/endometriosis/) and can be indicative of an alternative inflammatory condition such as appendicitis, [pelvic infection](https://nabtahealth.com/articles/pelvic-inflammatory-disease-a-simple-guide/) or ovarian cysts. Ideally an [endometriosis](https://nabtahealth.com/glossary/endometriosis/)\-specific marker, or panel of markers, will be found, enabling accurate diagnosis using a simple blood test, negating the need for more invasive treatment. Nabta is reshaping [women’s healthcare.](https://nabtahealth.com) We support women with their personal health journeys, from everyday wellbeing to the uniquely female experiences of fertility, pregnancy, and [menopause](https://nabtahealth.com/glossary/menopause/). Get in [touch](/cdn-cgi/l/email-protection#a1d8c0cdcdc0e1cfc0c3d5c0c9c4c0cdd5c98fc2cecc) if you have any questions about this article or any aspect of women’s health. We’re here for you. **Sources:** * Bazot, M, and E Daraï. “Diagnosis of Deep [Endometriosis](https://nabtahealth.com/glossary/endometriosis/): Clinical Examination, Ultrasonography, Magnetic Resonance Imaging, and Other Techniques.” _Fertility and Sterility_, vol. 108, no. 6, Dec. 2017, pp. 886–894., doi:10.1016/j.fertnstert.2017.10.026. * Hickey, M, et al. “[Endometriosis](https://nabtahealth.com/glossary/endometriosis/).” _BMJ_, vol. 348, 19 Mar. 2014, p. g1752., doi:10.1136/bmj.g1752. * Kennedy, S, et al. “ESHRE Guideline for the Diagnosis and Treatment of [Endometriosis](https://nabtahealth.com/glossary/endometriosis/).” _Human Reproduction_, vol. 20, no. 10, Oct. 2005, pp. 2698–2704., doi:10.1093/humrep/dei135. * May, K E, et al. “Peripheral Biomarkers of [Endometriosis](https://nabtahealth.com/glossary/endometriosis/): a Systematic Review .” _Human Reproduction Update_, vol. 16, no. 6, 2010, pp. 651–674., doi:10.1093/humupd/dmq009. * _Overview: [Endometriosis](https://nabtahealth.com/glossary/endometriosis/)_. NHS, [www.nhs.uk/conditions/](http://www.nhs.uk/conditions/endometriosis/)[endometriosis](https://nabtahealth.com/glossary/endometriosis/)/. Page last reviewed: 18/01/2019. * _[Endometriosis](https://nabtahealth.com/glossary/endometriosis/)_. Mayo Clinic, 24 July 2018, [www.mayoclinic.org/diseases-conditions/](http://www.mayoclinic.org/diseases-conditions/endometriosis/symptoms-causes/syc-20354656)[endometriosis](https://nabtahealth.com/glossary/endometriosis/)/symptoms-causes/syc-20354656.