Pros and Cons of Hormonal Treatments

Hormonal therapy remains the standard of first-line management for most women with endometriosis. These therapies aim to suppress ovulation and reduce menstrual flow, thereby limiting the stimulation of ectopic endometrial tissue.

Common hormonal options include:

• Combined oral contraceptive pill (COCP)
• Progestins
• Gonadotropin-releasing hormone (GnRH) agonists
• Levonorgestrel-releasing intrauterine device (LNG-IUD)

PROS:

Hormonal treatment is a widely accessible, non-invasive first-line option for managing endometriosis, often initiated in primary care. It can be effective in reducing pelvic pain, dysmenorrhoea, and dyspareunia, and is suitable for long-term use when tailored to individual needs and tolerance.

CONS:

However, hormonal therapies do not treat structured disease or adhesions. Side effects, such as mood changes, breakthrough bleeding, weight gain, and reduced bone density with GnRH agonists may impact adherence. Symptoms frequently recur after stopping treatment, particularly when underlying disease remains. GPs should consider these factors when discussing medical management with patients.

Choosing the right hormonal therapy depends on patient factors such as age, fertility plans, symptom severity, comorbidities, and tolerance to hormonal side effects. GPs are well-positioned to initiate and monitor these therapies, with referral warranted when symptoms persist despite optimal medical management.

When to Consider Laparoscopy

While hormonal therapy is effective for many patients, surgical intervention becomes necessary in specific scenarios, particularly when symptoms are severe, persistent, or suggestive of deep or complex disease.

Key indications for considering laparoscopy include severe or refractory pelvic pain despite adequate medical treatments, suspected deep infiltrating endometriosis involving areas such as the rectovaginal space, bladder, or bowel, and the presence of endometriomas (ovarian endometriotic cysts), especially if they are symptomatic or larger than 3-4 cm in diameter. Laparoscopy is also considered in cases of infertility, especially when there is concern about tubal damage or pelvic adhesions.

Laparoscopy is the gold standard for both diagnosing and treating endometriosis. It allows direct visualisation of lesions, surgical removal or ablation of endometrial tissue, and disintegration of adhesions. For patients struggling with infertility, it may improve natural conception rates, especially when minimal-to-moderate disease is present.

However, surgery carries inherent limitations and risks:

• Recurrence of endometriosis is common, particularly without post-operative hormonal suppression.
• Potential complications include injury to pelvic organs, haemorrhage, and post-surgical adhesions.
• In cases of ovarian endometriomas, aggressive excision may reduce ovarian reserve, impacting fertility potential.

A balanced discussion about the risks, benefits, and likely outcomes of surgery is essential. As a specialist in laparoscopic surgery, Dr Kelly Hankins works closely with referring GPs to ensure patients understand their options and receive timely, personalised care.

Post-Surgical Care and Long-Term Management

Surgical treatment is rarely the end of the journey. A multidisciplinary and long-term approach is key to preventing symptom recurrence and maintaining quality of life.

Post-operative care should include:

• Hormonal Therapy: Continued suppression is often recommended after surgery to reduce recurrence risk, particularly in patients not seeking pregnancy.
• Pelvic Physiotherapy: Useful for managing residual musculoskeletal pain, improving mobility, and addressing pelvic floor dysfunction.
• Psychological Support: Chronic pelvic pain and the impact of endometriosis on relationships, work, and fertility can contribute to depression and anxiety.

GPs play a critical role in ongoing patient support by monitoring treatment response and adjusting therapies as needed, addressing any side effects or changes in symptoms, and coordinating timely referrals to reproductive specialists, pain clinics, or allied health professionals. Collaborative care between GPs, gynaecologists, and other specialists is essential to ensure patients with endometriosis receive comprehensive, person-centred support throughout their treatment journey.

There is no one-size-fits-all approach to managing endometriosis. For many patients, medical management offers a safe and effective way to control symptoms and delay or avoid surgery. For others, particularly those with complex disease or fertility challenges, laparoscopy can be both diagnostic and therapeutic.

Understanding the strengths and limitations of each treatment pathway empowers GPs to guide patients towards the most appropriate care. Shared decision-making, continuity of care, and timely referral are essential to achieving the best outcomes.

If you have a patient experiencing persistent pelvic pain, suspected endometriosis, or infertility, Dr Kelly Hankins welcomes referrals for comprehensive evaluation and management.