Hormonal treatment for endometriosis

This article was medically reviewed by Andrew Horne, Professor of Gynaecology and Reproductive Sciences at Edinburgh University's MRC Centre for Reproductive Health.

The cyclical bleeding that happens during your period occurs when the endometrium breaks down in response to oestrogen and progesterone. Endometriotic lesions respond similarly to these hormones and will bleed, causing inflammation and pain.  

Hormonal therapies work to stop ovulation. They help to balance out your high oestrogen and progesterone levels, which will stop your lesions from growing and bleeding. This is temporary, meaning when you stop treatment, the hormone levels will rise again and your symptoms will come back.  

The oral contraceptives, progestin drug, and GnRH drug show similar relief from symptoms of endometriosis, so one drug is not superior to the other. However, some women are resistant to hormone therapy or exhibit unwanted side effects. In these cases, your physician will give you a new treatment plan with a different hormone drug and observe you for a few months for any relief from your symptoms. If you are still experiencing symptoms, your gynaecologist may suggest surgery as the next step.  

The COC contains a steady amount of oestrogen and progesterone. It can come in the form of an oral tablet, commonly known as the pill/birth control. It can also be delivered using a self-inserted vaginal ring that will need to be replaced every few weeks, or a patch that you can wear on your skin which also needs replacing.  

There are two ways to take your oral contraceptive tablet:

• The standard method is to take the pill once every day for 21 days, then take a break for seven days. You may spot or experience some bleeding at this time, but it is not menstrual blood like in a period.
• Alternatively, tricycling COC means continuously taking the packets with no break, so you will not get any monthly bleeding.  

If you choose to use a contraceptive patch, it is used for seven days then changed on the 8th day. This pattern continues for three weeks and is followed by a patch-free week. During this patch-free week, you may experience some spotting or bleeding. This is called withdrawal bleeding but it is not menstrual blood like in a period. After seven patch-free days, the cycle starts again (three weeks with a patch followed by one week without a patch).  

If you choose to use a contraceptive ring, the standard method is to insert it and leave it for 21 days. It is then removed for a seven-day ring-free week. After this week, a new ring is inserted and the cycle starts again. Another method is to have a shorter ring-free week or to skip it altogether and just put a new ring in.  

This therapy contains a component that is similar to progesterone, called progestin. This is another form of contraceptive, which primarily works by thickening the mucus of the cervix making it more difficult for sperm to pass through. It can be delivered in a pill form for daily use, or via intrauterine system (IUS) which is a ‘’T-shaped’’ device inserted into your uterus and needs to be replaced every five years by your gynaecologist. 

Whilst you are taking it, this will make your period lighter and less regular, and eventually stop them altogether. They will restart again once you have stopped.   

GnRH therapies have been shown clinically to reduce the size of endometriotic lesions and are typically recommended as a second-line treatment for endometriosis, which means you are likely to be prescribed one of the above pills first. These are administered by injection (or sometimes by nasal spray). They work by turning off the signals that tells the ovaries to produce oestrogen.  

GnRH drugs can have unwanted side effects after long term use, resulting in a decrease in bone density. Therefore, patients who respond well to GnRH drugs but want to avoid the side effects are prescribed with add-back hormone replacement therapy. In this method, other drugs are administered at low doses which helps to counteract the side effects of GnRH drugs.  

GnRH agonists stop your menstrual period by lowering oestrogen levels and creates a temporary, artificial menopause.

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