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You may want to have a say in this decision, or you may simply want to follow your doctor's recommendation. Either way, this information will help you understand what your choices are so that you can talk to your doctor about them.

Endometriosis: Should I Use Hormone Therapy?

Get the facts

Your options

This decision aid is for women who have mild symptoms and have not yet had laparoscopic surgery to diagnose or treat endometriosis. Hysterectomy and oophorectomy may be an option for women who have severe symptoms and have already tried hormone therapy and laparoscopic surgery.

Key points to remember

There is no cure for endometriosis. But hormone therapy can help relieve pain. Hormones work for up to 90 out of 100 women. This means that they don't work for 10 out of 100 women.

Hormone therapy is a good first choice for treatment, unless you want to get pregnant soon. Hormones may reduce the number and size of growths (implants) and keep them from spreading.

When your menstrual periods stop at around age 50 (menopause) and your estrogen levels drop, endometriosis growth and symptoms will probably also stop. (In some cases, scar tissue remains after menopause and can cause problems.)

Several hormones may be used. You would start with birth control hormones (such as a patch, pills, or a ring). They are usually the best choice for long-term use until menopause. If they don't help your symptoms, you could move to a stronger hormone. And if that one didn't help, you might try an even stronger hormone. The stronger hormones are often used only for a short time, because they have serious side effects.

If your doctor says it's okay, you can take non-steroidal anti-inflammatory drugs (NSAIDs) with or without hormone therapy to help your pain. Be safe with medicines. Read and follow all instructions on the label.

For some women, hormones reduce pain for only a short time. For others, relief lasts a long time.

The endometrium is the tissue that lines the uterus. During each menstrual cycle, a new lining grows, getting ready for a possible pregnancy. If you don't become pregnant during that cycle, the lining sheds. This is your menstrual period.

Endometriosis (say "en-doh-mee-tree-OH-sus") is the growth of this tissue outside of the uterus, usually on the or the fallopian tubes . It also may grow on the outside surface of the uterus, the bowels, or other organs in the belly.

These growths are called "implants." They grow, bleed, and break down with each menstrual cycle, just like the lining of the uterus does. In some women, this can cause pain and can make it hard to get pregnant.

Sometimes scar tissue forms around implants. This also can cause pain and trouble getting pregnant.

The female hormone , released by the ovaries, makes the implants grow.

While some women never have symptoms, others have severe pain. In some cases, the problem can affect how well your bowels, bladder, or other organs work.

Pain from implants may be mild for a few days before your menstrual period. It may get better during your period. But if an implant grows in a sensitive area such as the rectum, it can cause constant pain or pain during sex, exercise, or bowel movements.

Symptoms often get better during pregnancy and after childbirth and usually go away after menopause.

You likely will start treatment with birth control hormones. They are usually the safest hormones for long-term use. If they don't help your symptoms, you could take a stronger hormone. And if that one doesn't work, you could try an even stronger hormone. The stronger hormones are used only for a short time, because they have serious side effects.

Hormone therapy reduces estrogen levels in your body. Because of this, you can't use hormone therapy if you want to get pregnant.

Birth control hormones (such as a patch, pills, or a ring) stop and the growth of implants. These hormones can be used long-term until menopause.

Gonadotropin-releasing hormone agonist (GnRH-a) therapy lowers estrogen to the levels women have after menopause. It's usually used for only 3 to 6 months. Women sometimes take it with progestin to reduce side effects. GnRH-a is given as a shot or as a nasal spray.

Progestin lowers estrogen. It shrinks implants and reduces pain. Progestins are given as a shot or a pill. The levonorgestrel-releasing intrauterine device (LNG-IUD) is also used.

Danazol lowers estrogen levels and raises male hormone () levels. It shrinks implants and reduces pain for most women. Because of its side effects, though, it is not chosen as often as the other hormones. And it's used for no more than 6 to 9 months.

Aromatase inhibitors help stop the body from making estrogen. These medicines are used along with hormone treatment.

Hormones relieve the symptoms of endometriosis for up to 90 out of 100 women. This means that they don't work for 10 out of 100 women. You may have to try two or more types of hormones before you find one that works for you.

If taking birth control hormones works for you, you can use them for years (unless you plan to get pregnant).

For some women, hormones work for a while. For others, relief lasts a long time.

After treatment with any hormone therapy, pain may come back.

About 35 out of 100 women who use hormones for mild endometriosis have pain 5 years later. This means that 65 out of 100 women don't have pain 5 years later.

About 75 out of 100 women who use hormone therapy for severe endometriosis have pain 5 years later. This means that 25 out of 100 women don't have pain 5 years later.

These medicines have different side effects and risks. Some of them can make you feel like you're going through menopause.

Birth control hormones. Side effects are usually mild and often go away after the first few months. They can include spotting between periods, nausea, headaches, breast tenderness, and mood changes. There is a small increase in the risk of getting blood clots. Your doctor will not prescribe these hormones if you have had blood clots before, have had breast cancer, or are older than 35 and smoke.

Gonadotropin-releasing hormone agonist (GnRH-a). Side effects can include hot flashes, mood swings, vaginal dryness, less interest in sex, trouble sleeping, and headaches. Risks also include bone thinning.

Progestin. Side effects may include mood changes and depression, bloating and weight gain, weight loss, breast tenderness, and absent or light and irregular periods. High-dose progestin can cause bone thinning. Talk to your doctor about whether the progestin intrauterine device (Mirena) might give you the same benefits with fewer side effects.

Danazol. Side effects include decreased breast size, acne, and more facial and body hair. It can also cause deepening of the voice, which can be permanent. It can increase the risk of "bad" cholesterol.

Aromatase inhibitors. They can cause headaches, nausea, diarrhea, aching joints, and hot flashes. You also have a risk of bone thinning if you use these medicines for a long time.

Your doctor may advise you to try hormones if:

Your symptoms are mild.

You are close to menopause. Hormones might ease your symptoms until menopause.

Compare your options

Take hormones Take hormones

You take hormones as long as your doctor suggests. Depending on the hormone, you may take pills, use a patch, use a vaginal ring, use a nasal spray, or give yourself shots.

You may have tests to check for side effects, such as high cholesterol, depending on which hormones you take.

You may take non-steroidal anti-inflammatory medicines (NSAIDs), such as ibuprofen or naproxen, for pain.

Your symptoms may get better or go away.

You may be able to take hormones until menopause, when your symptoms should go away.

Hormones might not relieve your pain, or the pain could return after you stop taking the medicine.

Hormones have side effects that can include menopause symptoms, rapid bone loss, and an increase in cholesterol.

You could have side effects from NSAIDs used for pain.

Don't take hormones Don't take hormones

You may take NSAIDs, such as ibuprofen or naproxen, for pain.

You may have laparoscopic surgery instead, especially if you can't take hormones or you have fertility problems because of endometriosis.

You won't have side effects from hormones.

You can start trying to get pregnant sooner.

Your symptoms could continue or get worse.

If you have laparoscopic surgery, you have the risk of infection, bleeding, and damage to your bladder or bowels.

You could have side effects from NSAIDs used for pain.

The pain before and during my periods was so bad, I couldn't exercise. I am an active person, and the pain was really getting me down. I have had endometriosis for years and have tried ibuprofen and other medicines I could get at the drugstore, but they were not helping anymore. My doctor said taking birth control pills might help me. She said that also taking ibuprofen around the time of my period could really help. After a couple of months, I noticed enough of an improvement that I could do everything I used to. I'm especially happy that I can use this treatment for a long time, unlike other hormone therapies like Lupron.

I first noticed that my periods were becoming painful about a year ago. I wasn't too concerned, but I discussed the pain with my doctor when I went for a Pap smear. My examination and Pap smear were fine. My doctor said that endometriosis could be the cause of my pain. Since my mom and an older sister have had endometriosis, I wasn't too surprised. My doctor talked to me about my options. She told me that using ibuprofen, such as Advil or Motrin, might help my pain. Now I start taking ibuprofen the day before my period begins. It really helps relieve my pain. As long as ibuprofen helps my pain, I will wait before I try other treatment for my endometriosis.

I was surprised when my doctor told me endometriosis could be the cause of the pain I was having with my periods. I had never heard of endometriosis before. He explained what it was and told me about the treatments I could try. Taking birth control pills didn't help, and my doctor said a medicine called Lupron might stop the pain, though I could only take it for a few months. Treatment with Lupron worked. I hardly have any pain now, and taking a little estrogen for add-back therapy controlled the hot flashes without feeding the endometriosis.

My periods were really painful about 5 years ago. I went to my doctor, and he asked a lot of questions about my periods and did a pelvic examination and some tests. When all the tests came back normal, he said endometriosis might be the cause of my pain. I asked if waiting a few months to decide about treatment would be dangerous. He said waiting would be fine. After a few months, the pain eased up. I am glad I decided to wait and see.

What matters most to you?

Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.

Reasons to use hormone therapy

Reasons not to use hormone therapy

My other important reasons:

My other important reasons:

Where are you leaning now?

Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.

Using hormone therapy

NOT using hormone therapy

What else do you need to make your decision?

1. How sure do you feel right now about your decision?

3. Use the following space to list questions, concerns, and next steps.

Your Summary

Here's a record of your answers. You can use it to talk with your doctor or loved ones about your decision.

Which way you're leaning

How sure you are

Your comments

Key concepts that you understood

Key concepts that may need review

Author

Healthwise Staff

Primary Medical Reviewer

Sarah Marshall MD - Family Medicine

Primary Medical Reviewer

Thomas M. Bailey MD - Family Medicine

Primary Medical Reviewer

Martin J. Gabica MD - Family Medicine

Primary Medical Reviewer

Kathleen Romito MD - Family Medicine

Primary Medical Reviewer

Kirtly Jones MD - Obstetrics and Gynecology

1. Fritz MA, Speroff L (2011). Endometriosis. In Clinical Gynecologic Endocrinology and Infertility, 8th ed., pp. 1221-1248. Philadelphia: Lippincott Williams and Wilkins.

2. Lobo RA (2012). Endometriosis: Etiology, pathology, diagnosis, management. In GM Lentz et al., eds., Comprehensive Gynecology, 6th ed., pp. 433-452. Philadelphia: Mosby.

You may want to have a say in this decision, or you may simply want to follow your doctor's recommendation. Either way, this information will help you understand what your choices are so that you can talk to your doctor about them.

Endometriosis: Should I Use Hormone Therapy?

Here's a record of your answers. You can use it to talk with your doctor or loved ones about your decision.

1. Get the facts

2. Compare your options

3. What matters most to you?

4. Where are you leaning now?

5. What else do you need to make your decision?

1. Get the Facts

Your options

This decision aid is for women who have mild symptoms and have not yet had laparoscopic surgery to diagnose or treat endometriosis. Hysterectomy and oophorectomy may be an option for women who have severe symptoms and have already tried hormone therapy and laparoscopic surgery.

Key points to remember

There is no cure for endometriosis. But hormone therapy can help relieve pain. Hormones work for up to 90 out of 100 women. This means that they don't work for 10 out of 100 women.

Hormone therapy is a good first choice for treatment, unless you want to get pregnant soon. Hormones may reduce the number and size of growths (implants) and keep them from spreading.

When your menstrual periods stop at around age 50 (menopause) and your estrogen levels drop, endometriosis growth and symptoms will probably also stop. (In some cases, scar tissue remains after menopause and can cause problems.)

Several hormones may be used. You would start with birth control hormones (such as a patch, pills, or a ring). They are usually the best choice for long-term use until menopause. If they don't help your symptoms, you could move to a stronger hormone. And if that one didn't help, you might try an even stronger hormone. The stronger hormones are often used only for a short time, because they have serious side effects.

If your doctor says it's okay, you can take non-steroidal anti-inflammatory drugs (NSAIDs) with or without hormone therapy to help your pain. Be safe with medicines. Read and follow all instructions on the label.

For some women, hormones reduce pain for only a short time. For others, relief lasts a long time.

What is endometriosis?

The endometrium is the tissue that lines the uterus. During each menstrual cycle, a new lining grows, getting ready for a possible pregnancy. If you don't become pregnant during that cycle, the lining sheds. This is your menstrual period.

Endometriosis (say "en-doh-mee-tree-OH-sus") is the growth of this tissue outside of the uterus, usually on the or the fallopian tubes . It also may grow on the outside surface of the uterus, the bowels, or other organs in the belly.

These growths are called "implants." They grow, bleed, and break down with each menstrual cycle, just like the lining of the uterus does. In some women, this can cause pain and can make it hard to get pregnant.

Sometimes scar tissue forms around implants. This also can cause pain and trouble getting pregnant.

The female hormone , released by the ovaries, makes the implants grow.

How will endometriosis affect you?

While some women never have symptoms, others have severe pain. In some cases, the problem can affect how well your bowels, bladder, or other organs work.

Pain from implants may be mild for a few days before your menstrual period. It may get better during your period. But if an implant grows in a sensitive area such as the rectum, it can cause constant pain or pain during sex, exercise, or bowel movements.

Symptoms often get better during pregnancy and after childbirth and usually go away after menopause.

How do you take hormone therapy?

You likely will start treatment with birth control hormones. They are usually the safest hormones for long-term use. If they don't help your symptoms, you could take a stronger hormone. And if that one doesn't work, you could try an even stronger hormone. The stronger hormones are used only for a short time, because they have serious side effects.

Hormone therapy reduces estrogen levels in your body. Because of this, you can't use hormone therapy if you want to get pregnant.

Birth control hormones (such as a patch, pills, or a ring) stop and the growth of implants. These hormones can be used long-term until menopause.

Gonadotropin-releasing hormone agonist (GnRH-a) therapy lowers estrogen to the levels women have after menopause. It's usually used for only 3 to 6 months. Women sometimes take it with progestin to reduce side effects. GnRH-a is given as a shot or as a nasal spray.

Progestin lowers estrogen. It shrinks implants and reduces pain. Progestins are given as a shot or a pill. The levonorgestrel-releasing intrauterine device (LNG-IUD) is also used.

Danazol lowers estrogen levels and raises male hormone () levels. It shrinks implants and reduces pain for most women. Because of its side effects, though, it is not chosen as often as the other hormones. And it's used for no more than 6 to 9 months.

Aromatase inhibitors help stop the body from making estrogen. These medicines are used along with hormone treatment.

How well does hormone therapy work?

Hormones relieve the symptoms of endometriosis for up to 90 out of 100 women. This means that they don't work for 10 out of 100 women. You may have to try two or more types of hormones before you find one that works for you.

If taking birth control hormones works for you, you can use them for years (unless you plan to get pregnant).

For some women, hormones work for a while. For others, relief lasts a long time.

After treatment with any hormone therapy, pain may come back.

About 35 out of 100 women who use hormones for mild endometriosis have pain 5 years later. This means that 65 out of 100 women don't have pain 5 years later.

About 75 out of 100 women who use hormone therapy for severe endometriosis have pain 5 years later. This means that 25 out of 100 women don't have pain 5 years later.

What are the risks of taking these medicines?

These medicines have different side effects and risks. Some of them can make you feel like you're going through menopause.

Birth control hormones. Side effects are usually mild and often go away after the first few months. They can include spotting between periods, nausea, headaches, breast tenderness, and mood changes. There is a small increase in the risk of getting blood clots. Your doctor will not prescribe these hormones if you have had blood clots before, have had breast cancer, or are older than 35 and smoke.

Gonadotropin-releasing hormone agonist (GnRH-a). Side effects can include hot flashes, mood swings, vaginal dryness, less interest in sex, trouble sleeping, and headaches. Risks also include bone thinning.

Progestin. Side effects may include mood changes and depression, bloating and weight gain, weight loss, breast tenderness, and absent or light and irregular periods. High-dose progestin can cause bone thinning. Talk to your doctor about whether the progestin intrauterine device (Mirena) might give you the same benefits with fewer side effects.

Danazol. Side effects include decreased breast size, acne, and more facial and body hair. It can also cause deepening of the voice, which can be permanent. It can increase the risk of "bad" cholesterol.

Aromatase inhibitors. They can cause headaches, nausea, diarrhea, aching joints, and hot flashes. You also have a risk of bone thinning if you use these medicines for a long time.

Why might your doctor recommend hormones to treat your symptoms?

Your doctor may advise you to try hormones if:

Your symptoms are mild.

You are close to menopause. Hormones might ease your symptoms until menopause.

2. Compare your options

What is usually involved?

You take hormones as long as your doctor suggests. Depending on the hormone, you may take pills, use a patch, use a vaginal ring, use a nasal spray, or give yourself shots.

You may have tests to check for side effects, such as high cholesterol, depending on which hormones you take.

You may take non-steroidal anti-inflammatory medicines (NSAIDs), such as ibuprofen or naproxen, for pain.

You may take NSAIDs, such as ibuprofen or naproxen, for pain.

You may have laparoscopic surgery instead, especially if you can't take hormones or you have fertility problems because of endometriosis.

What are the benefits?

Your symptoms may get better or go away.

You may be able to take hormones until menopause, when your symptoms should go away.

You won't have side effects from hormones.

You can start trying to get pregnant sooner.

What are the risks and side effects?

Hormones might not relieve your pain, or the pain could return after you stop taking the medicine.

Hormones have side effects that can include menopause symptoms, rapid bone loss, and an increase in cholesterol.

You could have side effects from NSAIDs used for pain.

Your symptoms could continue or get worse.

If you have laparoscopic surgery, you have the risk of infection, bleeding, and damage to your bladder or bowels.

You could have side effects from NSAIDs used for pain.

Personal stories

Personal stories about treating endometriosis with hormone therapy

These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.

"The pain before and during my periods was so bad, I couldn't exercise. I am an active person, and the pain was really getting me down. I have had endometriosis for years and have tried ibuprofen and other medicines I could get at the drugstore, but they were not helping anymore. My doctor said taking birth control pills might help me. She said that also taking ibuprofen around the time of my period could really help. After a couple of months, I noticed enough of an improvement that I could do everything I used to. I'm especially happy that I can use this treatment for a long time, unlike other hormone therapies like Lupron."

"I first noticed that my periods were becoming painful about a year ago. I wasn't too concerned, but I discussed the pain with my doctor when I went for a Pap smear. My examination and Pap smear were fine. My doctor said that endometriosis could be the cause of my pain. Since my mom and an older sister have had endometriosis, I wasn't too surprised. My doctor talked to me about my options. She told me that using ibuprofen, such as Advil or Motrin, might help my pain. Now I start taking ibuprofen the day before my period begins. It really helps relieve my pain. As long as ibuprofen helps my pain, I will wait before I try other treatment for my endometriosis."

"I was surprised when my doctor told me endometriosis could be the cause of the pain I was having with my periods. I had never heard of endometriosis before. He explained what it was and told me about the treatments I could try. Taking birth control pills didn't help, and my doctor said a medicine called Lupron might stop the pain, though I could only take it for a few months. Treatment with Lupron worked. I hardly have any pain now, and taking a little estrogen for add-back therapy controlled the hot flashes without feeding the endometriosis."

"My periods were really painful about 5 years ago. I went to my doctor, and he asked a lot of questions about my periods and did a pelvic examination and some tests. When all the tests came back normal, he said endometriosis might be the cause of my pain. I asked if waiting a few months to decide about treatment would be dangerous. He said waiting would be fine. After a few months, the pain eased up. I am glad I decided to wait and see."

3. What matters most to you?

Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.

Reasons to use hormone therapy

Reasons not to use hormone therapy

My other important reasons:

My other important reasons:

4. Where are you leaning now?

Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.

Using hormone therapy

NOT using hormone therapy

5. What else do you need to make your decision?

Check the facts

1. Hormone therapy is a good first choice to treat endometriosis if I don't plan to get pregnant soon.

You're right. Hormone therapy is a good first choice for treatment, unless you want to get pregnant soon. Hormones may reduce the number and size of growths (implants) and keep them from spreading.

2. Some hormones can cause side effects that will make me feel like I'm going through menopause.

That's right. Some hormones just cause mild side effects. But some strong hormones can give you symptoms like those of menopause, such as hot flashes and vaginal dryness.

3. I can take hormone therapy as long as I want to without side effects.

You're right. Birth control pills have side effects but are safe for most women for long-term use until menopause. But other hormones should be taken for only a few months or a couple of years because of their side effects.

Decide what's next

1. Do you understand the options available to you?

2. Are you clear about which benefits and side effects matter most to you?

3. Do you have enough support and advice from others to make a choice?

Certainty

1. How sure do you feel right now about your decision?

2. Check what you need to do before you make this decision.

3. Use the following space to list questions, concerns, and next steps.

Primary Medical Reviewer

Sarah Marshall MD - Family Medicine

Primary Medical Reviewer

Thomas M. Bailey MD - Family Medicine

Primary Medical Reviewer

Martin J. Gabica MD - Family Medicine

Primary Medical Reviewer

Kathleen Romito MD - Family Medicine

Primary Medical Reviewer

Kirtly Jones MD - Obstetrics and Gynecology

1. Fritz MA, Speroff L (2011). Endometriosis. In Clinical Gynecologic Endocrinology and Infertility, 8th ed., pp. 1221-1248. Philadelphia: Lippincott Williams and Wilkins.

2. Lobo RA (2012). Endometriosis: Etiology, pathology, diagnosis, management. In GM Lentz et al., eds., Comprehensive Gynecology, 6th ed., pp. 433-452. Philadelphia: Mosby.

Note: The "printer friendly" document will not contain all the information available in the online document some Information (e.g. cross-references to other topics, definitions or medical illustrations) is only available in the online version.

Author: Healthwise Staff

Medical Review: Sarah Marshall MD - Family Medicine & Thomas M. Bailey MD - Family Medicine & Martin J. Gabica MD - Family Medicine & Kathleen Romito MD - Family Medicine & Kirtly Jones MD - Obstetrics and Gynecology

# data[].attributes.attachment_link.title
Endometriosis: Should I Use Hormone Therapy?

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You may want to have a say in this decision, or you may simply want to follow your doctor's recommendation. Either way, this information will help you understand what your choices are so that you can talk to your doctor about them. Endometriosis: Should I Use Hormone Therapy?

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Note: The data presented in these tables is developmental. The Ministry advises that you should not compare numbers between DHBs as:

some DHBs are experiencing delays in their ability to submit corrected data, so there are known gaps and inconsistencies

DHBs are working towards improvements in data quality and completeness, and the methodologies and assumptions they use to derive these measures are being refined.

Summary

These tables present developmental data sourced from the National Patient Flow Collection, and relates to Phase 1 of the programme. They show the number and percentage of referrals received during the specified period for publicly funded First Specialist Assessments by:

Responsible DHB

Specialty

Prioritisation Outcome of referrals (ie, accepted, declined, not decided and transferred)

Prioritisation Outcome reason for Declined and Transferred referrals.

These tables represent data from the new National Patient Flow Collection. They are intended to be a starting point for people looking to understand the scope of new information that is being gathered and the progress of the programme. When in full operation, the National Patient Flow Collection will benefit patients through a better understanding of demand for services, our capacity to meet that, and how access varies. It will improve knowledge of the complexities of the patient journey, so we can better link the services they need, and improve resources if there are constraints.

The referrals process

A person who has a condition they think may require treatment typically sees their primary care provider first. This is often, but not always, a GP. They will assess the person's condition and discuss the best options, including whether to refer the patient to a specialist (eg, an orthopaedic surgeon at a public hospital).

This referral for a First Specialist Assessment (an appointment between the patient and the specialist, at which the specialist assesses the person's condition and recommends the best option of care for them) is assessed by a prioritising clinician. The clinician then makes a decision whether the patient requires a specialist assessment by considering the person's level of need and their ability of benefit in comparison to others.

The clinician can decide whether to accept, decline or transfer the referral, or defer the decision and request for more tests to be conducted. A person with an accepted referral should receive a First Specialist Assessment within four months. Read more about how the the elective process works

The volume of declined and transferred referrals, and those pending test results and eligibility, forms the data which is being captured for the first time in New Zealand in the new National Patient Flow Collection.

Interpretation notes

Prioritisation Outcome of referral for First Specialist Assessment is based on the prioritising clinician's determination that the referral is for a First Specialist Assessment. It is not always clear from the referral what service is being requested.

Variation between DHBs is to be expected, even when the data is no longer considered as 'developmental', as each DHB has a different primary and secondary care environment.

Common terms used in the tables:

Responsible DHB is the DHB that is the principal contract holder for the delivery of the service

Accepted refers to a referral that has been accepted for a publicly funded First Specialist Assessment

Declined refers to a referral that has not been accepted for a publicly funded First Specialist Assessment. Reasons for declining a referral are presented in the following categories: below threshold, insufficient information, not eligible for publicly funded care and service not required

Not decided refers to a referral where the Prioritisation Outcome decision of the referral for a First Specialist Assessment is dependent on further test results (as ordered by the clinician) or confirmation of the patient's eligibility for publicly funded care

Transferred refers to a referral that has been transferred. Referrals may be transferred to another DHB or to another specialty.

Next update

Developmental data from the National Patient Flow collection will be published every three months. Revisions of earlier published data may occur at the same time. Additional information may be included as more data becomes available.

For further information about National Patient Flow email [email protected] .

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National Patient Flow: Prioritisation outcome of referrals for first specialist assessment tables (developmental)

# data[].attributes.attachment_link.description
Note: The data presented in these tables is developmental. The Ministry advises that you should not compare numbers between DHBs as: some DHBs are experiencing delays in their ability to submit corrected data, so there are known gaps and inconsistencies DHBs are working towards improvements in data quality and completeness, and the methodologies and assumptions they use to derive these measures are being refined.

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Class Notes

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Overview

Acupuncture involves the insertion of very thin needles through your skin at strategic points on your body. A key component of traditional Chinese medicine, acupuncture is most commonly used to treat pain. Increasingly, it is being used for overall wellness, including stress management.

Traditional Chinese medicine explains acupuncture as a technique for balancing the flow of energy or life force - known as chi or qi (chee) - believed to flow through pathways (meridians) in your body. By inserting needles into specific points along these meridians, acupuncture practitioners believe that your energy flow will re-balance.

In contrast, many Western practitioners view the acupuncture points as places to stimulate nerves, muscles and connective tissue. Some believe that this stimulation boosts your body's natural painkillers.

Why it's done

Acupuncture is used mainly to relieve discomfort associated with a variety of diseases and conditions, including:

Chemotherapy-induced and postoperative nausea and vomiting

Dental pain

Headaches, including tension headaches and migraines

Labor pain

Low back pain

Neck pain

Osteoarthritis

Menstrual cramps

Respiratory disorders, such as allergic rhinitis

Risks

The risks of acupuncture are low if you have a competent, certified acupuncture practitioner using sterile needles. Common side effects include soreness and minor bleeding or bruising where the needles were inserted. Single-use, disposable needles are now the practice standard, so the risk of infection is minimal. Not everyone is a good candidate for acupuncture. You may be at risk of complications if you:

Have a bleeding disorder. Your chances of bleeding or bruising from the needles increase if you have a bleeding disorder or if you're taking blood thinners.

Have a pacemaker. Acupuncture that involves applying mild electrical pulses to the needles can interfere with a pacemaker's operation.

Are pregnant. Some types of acupuncture are thought to stimulate labor, which could result in a premature delivery.

How you prepare

No special preparation is required before acupuncture treatment.

Choosing a practitioner

If you're considering acupuncture, take the same steps you would to choose a doctor:

Ask people you trust for recommendations.

Check the practitioner's training and credentials. Most states require that nonphysician acupuncturists pass an exam conducted by the National Certification Commission for Acupuncture and Oriental Medicine.

Interview the practitioner. Ask what's involved in the treatment, how likely it is to help your condition and how much it will cost.

Find out whether your insurance covers the treatment.

Tell your doctor you're considering acupuncture. He or she may be able to tell you about the success rate of using acupuncture for your condition or recommend an acupuncture practitioner.

What you can expect

Acupuncture treatment

During an acupuncture treatment, your acupuncturist inserts very thin needles into specific spots on your body. Insertion of the needles usually causes little discomfort.

Each person who performs acupuncture has a unique style, often blending aspects of Eastern and Western approaches to medicine. To determine the type of acupuncture treatment that will help you the most, your practitioner may ask you about your symptoms, behaviors and lifestyle. He or she may also closely examine:

The parts of your body that are painful

The shape, coating and color of your tongue

The color of your face

The strength, rhythm and quality of the pulse in your wrist

This initial evaluation and treatment may take up to 60 minutes. Subsequent appointments usually take about a half-hour. A common treatment plan for a single complaint would typically involve one or two treatments a week. The number of treatments will depend on the condition being treated and its severity. In general, it's common to receive six to eight treatments.

During the procedure

Acupuncture points are situated in all areas of the body. Sometimes the appropriate points are far removed from the area of your pain. Your acupuncture practitioner will tell you the general site of the planned treatment and whether you need to remove any clothing. A gown, towel or sheet will be provided. You lie on a padded table for the treatment, which involves:

Needle insertion. Acupuncture needles are inserted to various depths at strategic points on your body. The needles are very thin, so insertion usually causes little discomfort. People often don't feel them inserted at all. Between five and 20 needles are used in a typical treatment. You may feel a mild aching sensation when a needle reaches the correct depth.

Needle manipulation. Your practitioner may gently move or twirl the needles after placement or apply heat or mild electrical pulses to the needles.

Needle removal. In most cases, the needles remain in place for 10 to 20 minutes while you lie still and relax. There is usually no discomfort when the needles are removed.

After the procedure

Some people feel relaxed and others feel energized after an acupuncture treatment. But not everyone responds to acupuncture. If your symptoms don't begin to improve within a few weeks, acupuncture may not be right for you.

Results

The benefits of acupuncture are sometimes difficult to measure, but many people find it helpful as a means to control a variety of painful conditions.

Several studies, however, indicate that some types of simulated acupuncture appear to work just as well as real acupuncture. There's also evidence that acupuncture works best in people who expect it to work.

Acupuncture has few side effects, so it may be worth a try if you're having trouble controlling pain with more-conventional methods.

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Acupuncture involves the insertion of very thin needles through your skin at strategic points on your body. A key component of traditional Chinese medicine, acupuncture is most commonly used to treat pain. Increasingly, it is being used for overall wellness, including stress management.

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Author: Healthwise Staff

Medical Review: Sarah Marshall MD - Family Medicine & Thomas M. Bailey MD - Family Medicine & Martin J. Gabica MD - Family Medicine & Kathleen Romito MD - Family Medicine & Kirtly Jones MD - Obstetrics and Gynecology & Kevin C. Kiley MD - Obstetrics and Gynecology

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laparoscopic laser destruction of endometriosis

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laparoscopic laser destruction of endometriosis (procedure)

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Author: Healthwise Staff Medical Review: Sarah Marshall MD - Family Medicine & Thomas M. Bailey MD - Family Medicine & Martin J. Gabica MD - Family Medicine & Kathleen Romito MD - Family Medicine & Kirtly Jones MD - Obstetrics and Gynecology & Kevin C.

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Southern Cross Medical Library

The purpose of the Southern Cross Medical Library is to provide information of a general nature to help you better understand certain medical conditions. Always seek specific medical advice for treatment appropriate to you. This information is not intended to relate specifically to insurance or healthcare services provided by Southern Cross. For more articles go to the Medical Library index page.

Endometriosis is a common and often painful condition where tissue similar to the lining of the uterus (endometrium) is found outside the uterus.

Symptoms often include pelvic pain, atypical menstrual bleeding, and difficulty getting pregnant. In New Zealand, it is estimated the condition affects 120,000 girls and women. Endometriosis can usually be effectively managed through medication and/or surgery and lifestyle modifications.

Signs and symptoms

Painful periods can be the first sign that a girl or woman has endometriosis. The most common symptoms of endometriosis include:

Pelvic pain - usually, but not always, associated with menstrual periods. The pain can be severe and debilitating

Bowel-related symptoms such as bloating and fluctuating bowel habit, similar to irritable bowel syndrome (IBS)

Pain during or after sexual intercourse

Abnormal menstrual bleeding (heavy periods or bleeding between periods)

Pain with ovulation

Sub-fertility or infertility.

Other symptoms experienced may include:

Lower back pain

Constant tiredness/fatigue

Premenstrual syndrome (PMS)

Pain before or while passing urine or recurrent urinary tract infections.

Endometrial tissue can form lesions, nodules, and cysts, which are mostly found in the pelvis, the Pouch of Douglas, ovaries, bowel, ligaments, and bladder. Adhesions (fibrous scar tissue that causes internal organs or tissue to stick together) can also form. Cysts on an ovary (endometriomas) may develop in more advanced stages of the disease.

The severity of symptoms experienced is not generally related to the extent of the disease, eg: some women with mild endometriosis can suffer severe symptoms, and vice versa. Not every woman with endometriosis will have regular monthly symptoms. Symptoms of endometriosis usually improve during pregnancy and after menopause.

Causes

The cause of endometriosis is not fully understood. Endometriosis New Zealand says research continues around genetic, immunological, and environmental factors. The cause is now generally considered to involve a number of factors with a strong genetic link (if a woman's mother or sister has the condition then her likelihood of also developing endometriosis is increased).

Diagnosis

International studies indicate there's often a long delay - averaging eight years - from a first doctor visit with symptoms to diagnosis. For this reason, it is important for a girl or woman to play an active role in seeking help and accessing treatment, starting with talking with a doctor about all of her symptoms.

To aid diagnosis, a doctor will take a detailed medical history, assess signs and symptoms, and perform a pelvic examination. Sometimes other tests like an ultrasound are performed to assess the pelvis. While this is useful, and can identify cysts associated with endometriosis (endometriomas), it is not a diagnostic tool for endometriosis.

Endometriosis can only be definitively diagnosed with a laparoscopy. This is a surgical procedure performed under a general anaesthetic by a specialist gynaecologist.

The gynaecologist inserts a laparoscope (a long thin tube with a tiny camera at its tip) through a small incision in the tummy button to examine the abdomen and pelvis on a television monitor, looking for endometriosis, scarring and adhesions, or other abnormalities.

Endometriosis is often classified as minimal, mild, moderate, or severe; or recorded in clinical notes as stage I to IV based on American Society of Reproductive Medicine (ASRM) guidelines:

Minimal or stage I endometriosis: typically small patches, surface lesions or inflammation on or around organs in the pelvis.

Mild or stage II endometriosis: more extensive than stage I but limited infiltration of pelvic organs. Limited scarring or adhesions.

Moderate or stage III endometriosis: sometimes more widespread and starting to infiltrate pelvic organs, pelvic side walls or other structures. There may also be scarring and adhesions.

Severe or stage IV endometriosis: infiltrative disease affecting the pelvic organs and ovaries, often with distortion of the anatomy and extensive adhesions.

Treatment

Treatment of endometriosis is aimed at relieving symptoms and minimising complications. A treatment plan will consider a number of factors, including:

Severity of the condition

Impact on quality of life

Age

Intentions about having children

Treatment and management preferences.

Medical treatment
Medical treatment focuses on relief of symptoms through the use of pain-relieving medications and hormone treatment.

For mild cases of endometriosis, pain medications, eg: non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, alone may be sufficient to adequately relieve symptoms.

There are a number of different types of hormone treatments that can be used. The contraceptive pill can help to balance and regulate periods and often eases distressing symptoms. If you choose to go on the pill, it is important to be prescribed one that is best suited to your condition. The effectiveness of hormone treatment varies and may work best in cases of mild endometriosis.
Surgical treatment
Laparoscopic surgery aims to remove the endometriosis lesions and adhesions if they are found and restore normal anatomy. Whenever possible, laparoscopy will be undertaken in preference to laparotomy (open surgical procedure). Medical literature indicates surgical removal of the endometriosis is the gold standard treatment. It is important therefore that the gynaecologist has the appropriate surgical expertise to fully remove the endometriosis.

A hysterectomy is sometimes recommended where symptoms have significantly affected a woman's quality of life and where future fertility has been ruled out. The ovaries may also be removed (oophorectomy). In these cases, it may be necessary to commence menopausal hormone therapy (formerly known as hormone replacement therapy or HRT) after surgery.

A hysterectomy is not a cure for endometriosis but many women find relief particularly if endometrial tissue was found in the muscles of the uterus (adenomyosis). It is vital that all areas of endometriosis are excised at the same time. Discussion of any surgery should involve the woman so that she is fully informed and involved in her health decision making.
Lifestyle modification and alternative treatment
Self-management is encouraged in the treatment and management of endometriosis symptoms. Endometriosis NZ recommends regular exercise as the best non-drug treatment for pain. A gentle form of exercise, like walking, is recommended post-surgically or if symptoms have become very painful. Good sleep habits are also important.

Nutritional changes may ease irritable bowel-type symptoms. A diet low in fermentable carbs known as FODMAPS may be recommended. That means avoiding a range of foods including wheat, garlic, onions and some fruits and vegetables.

Further support

Endometriosis New Zealand is the organisation representing girls and women with endometriosis and pelvic pain in New Zealand and works with those who treat these conditions. ENZ offers information, support, and educational services and programmes.

Endometriosis New Zealand
Phone: (03) 379-7959
E-mail: info@nzendo.org.nz
Website: www.nzendo.org.nz

Fertility New Zealand offers support and education for couples with infertility problems.

Fertility New Zealand
Freephone: 0800 333 306
E-mail: support@fertilitynz.org.nz
Website: www.fertilitynz.org.nz

References

Endometriosis New Zealand (2017). About endometriosis (Web Page). Christchurch: Endometriosis New Zealand. http://www.nzendo.org.nz/about-endometriosis [Accessed: 07/05/20]
Evans, S., Bush, D. (2016). Endometriosis and pelvic pain (3rd ed.). Susan F. Evans Pty Limited
Fertility New Zealand (2017). Endometriosis and infertility (Pamphlet PDF). Auckland: Fertility New Zealand. http://www.fertilitynz.org.nz/files/4314/8520/6268/0117_Endometriosis_web.pdf
Ministry of Health (2020). Diagnosis and management of endometriosis in New Zealand (PDF). Wellington: New Zealand Government Ministry of Health. https://www.health.govt.nz/system/files/documents/publications/diagnosis-and-management-of-endometriosis-in-new-zealand-mar2020.pdf
O'Toole, M.T. (Ed.) (2017). Endometriosis. Mosby's Dictionary of Medicine, Nursing & Health Professions (10th ed.). St Louis, MI: Elsevier.

Last reviewed - June 2020

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Endometriosis - symptoms, surgery, treatment

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The purpose of the Southern Cross Medical Library is to provide information of a general nature to help you better understand certain medical conditions. Always seek specific medical advice for treatment appropriate to you. This information is not intended to relate specifically to insurance or healthcare services provided by Southern Cross.

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Christchurch Acupuncture Centre provides high quality treatments for people who suffer a range of conditions including:

muscular-skeletal problems such as neck/shoulder pain, back pain, lower back pain, frozen shoulder, tennis elbow, RSI, knee and ankle problems

sports and work injuries

sciatica, arthritis, headaches and migraines

insomnia, depression, morning sickness

asthma, hayfever, sinus

acne, eczema, shingles

craving for cigarettes, sugar, drugs and alcohol

irregular or painful periods, menopausal symptoms

Christchurch Acupuncture Centre is directed by Mr. Patrick Guo, who has 28 years of experience with alternative medical treatments including acupuncture, acupressure, moxibustion, reflexology and sports massages.

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Chinese acupuncture treatment | Chch Acupuncture Centre

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Christchurch Acupuncture Centre provides high quality treatments for people who suffer a range of conditions including: muscular-skeletal problems such as neck/shoulder pain, back pain, lower back pain, frozen shoulder, tennis elbow, RSI, knee and ankle problems sports and work injuries sciatica, arthritis, headaches and migraines insomnia, depression, morning sickness asthma, hayfever, sinus acne, eczema, shingles craving for cigarettes, sugar, drugs and alcohol irregular or painful periods, menopausal symptoms Christchurch Acupuncture Centre is directed by Mr. Patrick Guo, who has 28 years of experience with alternative medical treatments including acupuncture, acupressure, moxibustion, reflexology and sports massages.

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Similar to the lining of the uterus, endometriosis usually responds to estrogen and progesterone, the hormones that control your menstrual cycle. The natural fluctuations (or rise and fall of the amounts) of these hormones can increase the activity of endometriosis and aggravate symptoms, whereas steady medical doses of estrogens, progestins, and other medications that decrease natural hormone production can lessen endometriosis "flare ups."

As a general rule, women are less likely to have problems with endometriosis before their first menstrual period or after menopause. On the other hand, women with endometriosis tend to experience more symptoms around their period. It is also believed that endometriosis may form when menstrual tissue flows backwards through the fallopian tubes and implants in the abdominal cavity and pelvis. Thus, suppressing (stopping) your period with the following hormonal medications can help relieve endometriosis-related pain and prevent endometriosis from developing or becoming worse over time.

Continuous Estrogen/Progestin Hormonal Therapy

Medications containing a combination of an estrogen and a progestin can be used to control your periods and suppress the activity of endometriosis. The most common combination of estrogen and progesterone is in the form of the birth control pill, but hormones can also be delivered by a vaginal contraceptive ring (Nuvaring ®) that lasts 3-4 weeks or a patch (Ortho Evra ®) that you wear on your skin and change weekly. All hormonal medications appear to be most effective against endometriosis when used in a continuous fashion. This means that you use an active pill, ring, or patch daily, and skip the hormone-free week when you would normally have your period.
Instructions on How to take Continuous Combined Hormonal Therapy

Birth Control Pills - Take one active pill every day at the same time

Vaginal Ring - Insert a new vaginal ring every 3-4 weeks

Patch - Change your patch weekly

Continuous use is as easy as skipping the inactive pills in your pill pack or replacing your ring/patch as soon as it would normally be time to remove the old one. In doing so, you will decrease the number of bleeding days that you have and prevent pain associated with your period.

Continuous combined estrogen and progestin therapy is safe and well-tolerated by most women. The estrogen/progestin therapies also provide reliable contraception but do not protect from sexually transmitted diseases (STDs). The most frequently encountered problem is unscheduled "breakthrough" bleeding or spotting, which usually becomes less frequent the longer you are on the hormone treatment. Taking the pill at the same time every day and avoiding missed pills helps to prevent break-through bleeding. Some women who are at higher risk for blood clots or stroke should not take hormonal therapies with estrogen. Talk to your gynecologist to see whether or not continuous combined estrogen/progestin treatment is right for you.

Continuous Progestin Hormonal Therapy

Progestins, or "progesterone-like" hormones, are one of the components found in combined estrogen/progestin treatments, like the birth control pill (see medical treatments: continuous estrogen/progestin). Progestins alone are also effective in treating endometriosis. When taken in a long-term continuous fashion, progestins tend to thin the lining of the uterus which stops regular periods and lessens the chance for break-through bleeding or spotting and has similar activity against endometriosis lesions themselves.

There are various forms of synthetic progesterone called, "progestins" that are used to treat endometriosis. When treating young women, we prefer to start with a daily pill, such as a progesterone "birth control pill" sometimes referred to as a "mini-pill" or norethindrone acetate (Aygestin ®). These medications should be taken at the same time every day to lessen the chance of unscheduled "breakthrough" bleeding (spotting) and pain. Setting the alarm on your cell phone can be a good reminder to take your medication at the same time each day. The "mini-pill" is considered a slightly less effective contraceptive and Aygestin is not considered a contraceptive and may not protect against pregnancy. There are at least two long-acting progestin-only contraceptive methods, which may be useful in treating endometriosis: (1) injectable medroxyprogesterone (Depo-Provera ®) and (2) the levonorgestrel intrauterine device (Mirena ® IUD).
Progestin-only treatments
Method: Pills
Examples: Norethindrone acetate (Aygestin ®), Progestin only birth control pills (Camila, Nor-QD), Medroxyprogesterone acetate (Provera ®)
How Medication is Taken: Daily Pills Method: Injections Examples: Medroxyprogesterone (Depo-Provera ®) How Medication is Taken: One shot every 3 months

Method: Intrauterine Device (IUD)
Examples: Levonorgestrel-releasing IUD (Mirena ®)
How Medication is Taken: Small "t-shaped" device inserted into the uterus, releases medication for up to 5 years

Each of these progestin-only methods can make your periods lighter and less frequent or stop them altogether. Continuous progestins are safe, effective and well-tolerated by most women. Weight gain, bloating, and depression are sometimes reported. Irregular or unscheduled "breakthrough" bleeding can occur also but usually becomes less frequent the longer you use the medication. You should discuss the pros and cons of continuous progestin-only hormone therapy with your gynecologist to see if one of these methods is right treatment for you.

Danazol

Danazol is a synthetic androgen (male hormone) which is an effective medical treatment for endometriosis.

It is given as a pill 2-4 times daily in doses of 400-800 mg per day

It works by making the active endometriosis implants "inactive" or atrophic so they do not grow

When endometriosis implants become inactive pelvic pain often decreases.

Danazol also lowers estrogen levels which is helpful in the treatment of endometriosis.

Danazol may be prescribed for other uses such as fibrocystic breast disease.

Side effects may include:

Changes in the menstrual cycle; no periods, irregular periods or spotting

Mild weight gain

Bloating

Some women will experience androgenic (male hormone) side effects including hair growth, acne, oily skin and/or oily hair. All of these side effects are reversible when the medication is stopped however; it may take up to 6-9 months for the effects to resolve completely.

Irritability and/or nervousness

A rare but non-reversible side effect is deepening of the voice

Rare side effects may include pressure in the brain, including stroke, liver disease and bleeding in the abdomen.

Before taking Danazol:

It is very important to tell your doctor if you are taking other prescription or nonprescription medicines including herbs and vitamins.

Be sure to tell your doctor if you suffer from migraine headaches; heart, kidney, liver disease or if you have ever had a seizure.

Warning:

Danazol should not be taken if you are pregnant or breastfeeding

A non-hormonal type of birth control to prevent pregnancy must be used if you are sexually active.

If you become pregnant while taking Danazol, call your doctor right away.

Lupron® with Add-back

Another highly effective way to treat endometriosis is to lower the natural estrogen levels altogether by giving an injectable medication, called leuprolide acetate (Lupron ®). This medication is given as a shot every 1 or 3 months depending on the dose. When given continuously, Lupron ® turns off the chain of hormonal signals that tell the ovaries to make estrogen. This stops your menstrual period and lowers estrogen levels to a point where endometriosis becomes inactive.

Similar to continuous hormonal therapies, Lupron ® can be associated with irregular bleeding at first but usually results in cessation of periods over time. Women should know that they may have a "flare up" of symptoms shortly after they receive their first dose of medication because estrogen levels usually increase for days to weeks before they fall, causing a temporary menopause-like condition. Later, low estrogen levels may contribute to hot flashes (episodes of feeling suddenly hot, flushed, and sweaty), mood changes, vaginal dryness, and other symptoms that are typically associated with menopause. Over time, low estrogen levels may lead to low bone mineral density and possibly fragile bones that are at greater risk for fracture.

However, there is a way to get the most benefit from Lupron ® with minimal or no side effects. We always prescribe low-dose hormonal "add-back" medication such as daily Aygestin (see medical treatments: continuous progestin) or a combined estrogen/progestin add-back regimen, along with Lupron ®. Add-back therapy offsets the side effects of Lupron ® which results in a high degree of patient satisfaction while still suppressing endometriosis. Your doctor may monitor your bone mineral density with a DXA scan if you have been on Lupron for 6 months or longer. We do not recommend Lupron ® for females less than 16 years of age. Talk to your gynecologist about whether Lupron ® with add-back therapy is the right treatment for you.

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Endometriosis Medical Treatment - Brigham and Women's Hospital

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Similar to the lining of the uterus, endometriosis usually responds to estrogen and progesterone, the hormones that control your menstrual cycle. The natural fluctuations (or rise and fall of the amounts) of these hormones can increase the activity of endometriosis and aggravate symptoms, whereas steady medical doses of estrogens, progestins, and other medications that decrease natural hormone production can lessen endometriosis "flare ups."

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Between 1% and 10% of Australian women have endometriosis, a condition where the tissue that normally lines the uterus, the endometrium, grows outside the womb.

There is typically a delay of six to seven years between first symptoms and diagnosis of endometriosis. The disease is most commonly progressive, so if women have symptoms and it goes untreated, it may grow and worsen.

The only way to definitively diagnose endometriosis is through key-hole surgery or laparoscopy, where a surgeon examines the pelvis for signs of the disease. This invasive procedure requires general anaesthesia and hospitalisation.

Read more: Health Check: are painful periods normal?

Many women with period pain, especially adolescents, who could have endometriosis but don't have a (laparoscopy-confirmed) diagnosis are prescribed the pill to reduce their pain. These women may only be diagnosed with the disease once they stop taking the pill and their symptoms return or increase.

While early diagnosis is ideal, endometriosis is thought to be less likely to progress while women are taking the pill, making a delayed diagnosis less worrying.

But when it comes to managing endometriosis, not all contraceptives are equal. And what works for one woman many not be the best choice for another.

What causes endo pain?

Most women experience "retrograde menstruation", when menstrual blood and endometrial cells move back up the fallopian tubes and into the abdomen. In women with endometriosis, the endometrial cells attach to pelvic or abdominal organs - including the ovaries, bladder and bowel - and start to grow.

During menstruation, these "rogue" endometrial cells form lesions that bleed in the same way as the lining of the uterus. This results in a vicious cycle of inflammation and scarring within the abdomen which causes infertility, painful periods, painful sex and persistent pelvic pain that lasts throughout the menstrual cycle.

Endometriosis can be difficult to diagnose, particularly in its early stages. While the disease is common, many women have painful periods that are not caused by endometriosis. The only way to tell for sure is to have surgery, which women are rightly reluctant to commit to unless symptoms become severe.

Contraceptive treatments

Pain from endometriosis can be treated surgically by removing the lesions. If it is all removed or destroyed, then 80% of women will experience improvement in their pain symptoms. Endometriosis will regrow in about one-third of women over the next five years, so multiple surgeries may be needed.

In women with infertility, there is almost a doubling of natural pregnancy rates after surgery for endometriosis.

Read more: Women aren't responsible for endometriosis, nor should they be expected to cure themselves

An alternative approach is to use hormonal contraceptives to suppress menstruation or replace it with a milder version of menstruation, called a "withdrawal bleed". Suppressing menstruation stops the lesions bleeding and prevents new endometrial cells reaching the abdomen.

The most common form of hormonal contraceptive is the combined oral contraceptive pill, which contains oestrogen and a progesterone-like hormone, progestin. The pill is safe to use in the long term, doesn't cost much, is generally well tolerated, and also protects against pregnancy.

The combined pill is often prescribed as the first line of treatment, with the aim of reducing pain. If it controls symptoms (pain), then the assumption is that underlying disease is not progressing.

Withdrawal bleeds while on the combined pill are generally much lighter than regular periods. They don't involve significant endometrial shedding, which in theory reduces the risk of endometriosis.

If the combined pill is taken continuously without the sugar pills, some women's menstrual bleeds stop altogether. This can reduce or eliminate period pain and, hopefully, control the disease.

Fongbeerredhot/Shutterstock

However, endometriosis is an oestrogen-dependent disease. So, taking oestrogen and having regular hormone exposure with monthly bleeds could result in ongoing pain symptoms and disease progression. If this is the case, progesterone-only pills are another option.

Progesterone-only pills such as Microlut, Provera, Dimetriose and Visanne contain progestin and no oestrogen. They suppress endometrial growth and often stop menstruation.

But they don't suit everyone. Some women report significant side effects from progesterone-only pills, such as changes in mood, fluid retention (bloating, weight gain, breast enlargement), reduced libido, increased hair growth, oily skin and acne. The side effects vary, depending on the type of progestin, and the woman's individual reaction.

Another option is the Mirena intra-uterine device (IUD), which releases progestins directly into the uterus. It is highly effective at stopping uterine endometrial growth and reducing menstruation.

A possible side effect is unpredictable bleeding and spotting, which some women find unacceptable.

What we don't know

There is a shortage of good evidence-based science around the use of the pill to treat endometriosis symptoms. Much of what we know is based on an understanding of how hormones drive endometrial growth, coupled with practical clinical experience and observation.

Read more: Pregnancy doesn't 'cure' endometriosis, so where does this advice come from?

We presume that long-term suppression of menstruation with the pill halts the progression of endometriosis. Unfortunately, a good clinical trial investigating this would be impossible to run since it would include doing laparoscopies on some women who don't have symptoms, which would be unethical.

We also suspect, but don't know for certain, that once significant scarring and damage has occurred due to ongoing disease, the pill is much less likely to be effective in suppressing symptoms.

If the pill is effective in controlling symptoms, women may only be diagnosed with endometriosis once they stop taking it. This creates a paradox whereby treating young women for their pain results in a delay in diagnosing the disease. But because endometriosis is less likely to progress while women are taking the pill, such a delay is less worrying than if the symptoms went unmanaged.

Ultimately, individual variability plays a large role in the symptoms women experience with endometriosis and the response to the various contraceptives available on the market. So it's important to discuss the best course of treatment with your doctor.

You may need to shop around to find a GP or gynaecologist who specialises in treating endometriosis. Don't be afraid to ask how much they know about the disease and their attitude towards various treatments to see if they're the right fit for you.

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What happens to endometriosis when you're on the pill?

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Between 1% and 10% of Australian women have endometriosis, a condition where the tissue that normally lines the uterus, the endometrium, grows outside the womb. There is typically a delay of six to seven years between first symptoms and diagnosis of endometriosis.

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Study design

This randomized trial will be conducted in four centers: the Second Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, the Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, the Qionghai Hospital of Traditional Chinese Medicine and the Ganzhou Maternal and Child Health Care. A total of 106 patients diagnosed with pelvic pain related to endometriosis will be enrolled in this trial (Additional file 1).

Participants

Participants will be recruited only if they satisfy all of the inclusion criteria and do not meet any of the exclusion criteria. See Fig. 1 for the participant flow diagram.

Inclusion criteria

1. 1.
Women aged between 20 and 40 years

2. 2.
Endometriosis diagnosed according to the Endometriosis Consensus Guidelines (Chinese Medical Association, 2015): (1) symptomatic endometriosis detected by laparoscopy or laparotomy or (2) ovarian endometrioma detected by ultrasound or magnetic resonance imaging with pelvic pain

3. 3.
Patients willing to receive acupuncture for pain relief

4. 4.
Pelvic pain score equal to or above 4 cm on the Visual Analog Scale (VAS)

5. 5.
Regular menstrual cycle

6. 6.
Signed informed consent

Exclusion criteria

1. 1.
Pelvic ultrasound demonstrates that the endometrial cyst measures more than 5 cm in diameter and surgery is indicated

2. 2.
Imaging examination suspects pelvic genital malignancy

3. 3.
Cancer antigen-125 level > 200 IU/L

4. 4.
Pelvic infectious disease

5. 5.
Other severe disorders in the heart, lung, liver, kidney, or mental disorders causing inability to cooperate in the study

6. 6.
Patients who have received any other treatment for endometriosis that may affect the observation of the curative effects of acupuncture over 3 months

7. 7.
Pregnancy or breastfeeding

8. 8.
Refusal to be randomized

Interventions

This study has two phases. The first phase will include 3 months of acupuncture treatment, and the second phase will include 3 months of follow-up without treatment. Patients will be randomly assigned to one of two groups in a 1:1 ratio, either the treatment group or the control group. Then, acupuncture treatment will start and last for 3 months following by 3 months of follow-up.

The whole acupuncture treatment will be carried out by two experienced acupuncturists who have received a license from the Ministry of Health of China and have practiced clinically for more than 5 years. Every acupuncture session will be once a day, three times a week and last for 30 min and only start from 7 days before the expected menstrual onset. During the menstrual period, they will receive acupuncture every day when they have endometriosis-associated pelvic pain.

Treatment group

The design of the treatment group is guided by the theory of Traditional Chinese Medicine. Disposable, sterile, stainless-steel needles, 0.30 × 40 mm, will be inserted into the acupoints on the abdomen and legs for 15 to 35 mm. The participants assigned to the treatment group will receive acupuncture at bilateral Sanyinjiao (SP6), Zhaohai (KI6), Taichong (LR3), Qichong (ST30) and at Guanyuan (CV4) for a total of nine needles see (Table 1) [ 13]. After insertion, all acupuncture needles will be stimulated manually by rotating the needle quickly with the thumb and forefinger to evoke the needle sensation ( De Qi) once every 10 min.

Control group

The control group will receive acupuncture at non-acupoints. Disposable, sterile, stainless-steel needles will be inserted superficially to a depth of < 5 mm on each shoulder and upper arm, without any stimulation.

Primary outcome

Pelvic pain

The primary outcome is pelvic pain that include dysmenorrhea, intermenstrual pain and dyspareunia. They will be assessed on a VAS scale [ 14]. On the VAS scale, a 100-mm horizontal line from no pain on the far left to the worst possible pain on the far right is scored by determining the distance from the far left to the edge of the mark made by the patient. The distance represents pain intensity. The VAS will be assessed at baseline, the first, second and third menstrual cycles and the follow-up period. See Table 2 for the study design schedule.

Secondary outcomes

Endometriosis-specific quality of life

The Endometriosis Health Profile − 30 (EHP-30) [ 15] will be used to evaluate the effects of endometriosis on patients' lives. This questionnaire includes two parts. The first part is the core questionnaire applicable to all patients with endometriosis, which includes five dimensions and 30 items. The second part of the modular questionnaire includes 23 items and six dimensions; each dimension is specific to the endometriosis patient: employment, relationship with children, sex, feelings about the medical profession, treatment and infertility. Each item is rated at five grades from 0 as "never" to 4 as "always." The EHP-30 will be assessed at the baseline period, the third menstrual cycle during treatment and the third menstrual cycle in the follow-up period.

Physical functioning

Physical functioning will be assessed by the Multidimensional Pain Inventory (MPI) [ 16]. This questionnaire includes three parts. The first part is the influence of pain on patients' daily lives, the second part is the response of patients' significant other to patients regarding pain, and the third part is the ability of patients to participate in daily activities. Each item is scored at seven grades from 0 to 6. The MPI will be assessed at the baseline period, the third menstrual cycle during treatment and the third menstrual cycle in the follow-up period.

Emotional functioning

Emotional functioning will be evaluated by the Beck Depression Inventory (BDI) [ 17] and Profile of Mood States (POMS) [ 18]. The BDI consists of 13 items of emotional, behavioral and somatic symptoms. Each item is scored from 0 to 3 and measure sadness, pessimism, sense of failure, lack of satisfaction, guilty feelings, sense of punishment, self accusations, social withdrawal, indecisiveness, body image, work inhibition, fatigability and loss of appetite. The POMS is a psychological rating scale used to assess distinct mood states and measure six different dimensions of mood swings. These include: tension, depression, anger, vigor, fatigue and confusion. A 5-point scale ranging from "not at all" to "extremely" is administered to patients to assess their mood states. The BDI and POMS will be assessed at the baseline period, the third menstrual cycle during treatment and the third menstrual cycle in the follow-up period.

Patient satisfaction

The Patient Global Impression of Change (PGIC) [ 19] will be used to assessed patients' satisfaction for their changes (improvement or decline) in clinical status. The PGIC is a single-item questionnaire used to assess improvement with therapy. A 7-point scale ranging from "very much better" to "very worse" is used to assess their satisfaction states. The PGIC will be assessed at the baseline period, the third menstrual cycle during treatment and the third menstrual cycle in the follow-up period.

Pain diary

Pain diaries will be used to record the specific time and frequency of pain attacks, the duration of pain, the changes of intensity, the start time of pain relief and any medication used for patients. Pain diaries will be assessed at the baseline period, the first, second and third menstrual cycles and at follow-up.

Follow-up

The goal of follow-up is to evaluate the long-term efficacy of acupuncture on pain relief. The follow-up assessments will be performed after treatment and will last for 3 months. During the follow-up period, patients will continue to maintain pain diaries and complete the questionnaires. They can submit the relevant information to researchers via email or short message service. Researchers will also pay close attention to changes in patient illness.

Randomization and blinding

One hundred and six eligible patients will be randomly assigned to either the treatment group or the control group in a 1:1 ratio after all baseline assessments. The random allocation sequence was generated by a computer. A researcher who does not participate in treatment, data collection and evaluation will provide the random number and group assignment to each center. The randomization is blinded and allocation is hidden. Owing to the unique nature of the acupuncture operation, it is impossible for the acupuncturists to be blinded. However, patients, the data collector and the statistician will be blinded.

Sample size calculations and statistical analysis

This trial will use a clinical-superiority design that aims to verify that the curative effect of acupuncture is better than that of comfort needles. The primary outcome measure is proposed to be the VAS. The minimal important difference (MID) for improvement on the VAS was found to be − 3.9 cm and/or − 49% [ 20]. According to our pre-experimental treatment of women with pain related to endometriosis, assuming the standard deviation (SD) to be 1.7 and the difference between two treatment effect to be 3, the statistical power is 80% and the significance level is 0.05. According to the formula [ 21]:

where N represents size per group, Z 1-α is Type I error, Z 1-β is Type II error, δ is expected SD of the population being sampled, δ ₀ is tolerable error in distance from mean value and S ² is SD. So it requires each group to contain no less than 44 patients. With an estimated 20% dropout rate, we plan to recruit 53 patients for each group, for a total of 106 patients.

Data will be summarized with counts for categorical variables present as mean and SD for normally distributed variables, or median (interquartile) for the variables not normally distributed. Missing data will be imputed according to the last-observation-carried-forward (LOCF) [ 22] principle. The data will be subjected to intent-to-treat analysis. A statistician blinded to the group settings will perform the statistical analysis. The between-group difference will be compared by analysis of covariance. The variables not normally distributed will be assessed by the rank-sum test. If participants have taken analgesics during the trial, they will be excluded from the analysis and the rate difference of outcomes between the two groups will be analyzed. Statistical significance will be set at P  < 0.05.

Data entry and quality control of data

All clinical data will be recorded in the case report form. Researchers must fill in the case report form. Any corrections will be explained in the appended notes signed and dated by the physicians. Supervisors will check each case report form to make sure that the trial data are recorded in a timely manner, accurately and completely. Data input will be done separately by two data collectors with computers. The data manager will examine the data in the database to confirm that it is consistent with the data in the case report form and run a database consistency check.

Security

Possible adverse events due to acupuncture, such as discomfort, sweating, hematoma, fainting, severe pain, and metal allergy symptoms, will be recorded by the researcher.

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Efficacy of acupuncture on pelvic pain in patients with endometriosis: study protocol for a randomized, single-blind, multi-center, placebo-controlled trial

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Background Endometriosis is a chronic gynecological disease that is characterized by the presence of endometrial tissue outside the uterine cavity. The main symptoms include dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. These symptoms impair the lives of most of the women suffering from the disease.

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Introduction

Endometriosis is a chronic, oestrogen-dependent, inflammatory disease that affects 5%-15% of reproductive-age women, causing infertility and pain-specifically chronic pelvic pain, deep dyspareunia, dysmenorrhoea, dyschezia, and dysuria [ 1- 4]. It may be that endometriosis-related changes are caused by plastic changes in the peripheral and central nervous systems, and such changes may in fact predispose for other long-lasting pain conditions [ 5]. Therefore, it is important that researchers develop strategies to alleviate pain.

Current pain therapies often involve various pharmacological and surgical treatments, and the symptoms of endometriosis are frequently treated using oestrogen-gestagen combinations or gonadotropin-releasing hormone (GnRH) agonists that block the menstrual cycle. However, many such interventions do not sufficiently affect perceived pain, and pain relapses are possible [ 6- 8]. Furthermore, they can have considerable side effects, such as menopausal disorders, that represent an additional handicap for affected women [ 9].

Thus, acupuncture may serve as a complement or alternative to these treatments. The pain-alleviating effects of acupuncture have been attributed to various physiological and psychological processes, such as activation of endogenous descending pain inhibitory systems, deactivation of brain areas that transmit pain-related signals, interaction between nociceptive impulses and somato-visceral reflexes, and the expectation of symptom relief [ 10- 12].

Cancer antigen 125 (CA-125), a well-established marker of epithelial cell ovarian cancer, is derived from coelomic epithelia, including those of the endometrium, fallopian tubes, ovaries, and peritoneum [ 13]. In endometriosis, CA-125 levels are elevated through stimulation of coelomic epithelia [ 14]. In previous studies, we have found a strong association between preoperatively elevated CA-125 levels and advanced stage of disease [ 15]. Similarly, Amaral et al. reported that women with more advanced degrees of endometriosis showed higher CA-125 levels in both serum and peritoneal fluid [ 16]. However, many studies have reported that acupuncture can reduce the level of serum CA-125, relieving the pelvic cavity pain that is associated with endometriosis [ 17- 20]

The purpose of this systematic review and meta-analysis was to determine the effectiveness of acupuncture in treating endometriosis-related pain.

Materials and methods

Electronic searches

We adopted the Cochrane Menstrual Disorders and Subfertility Group (MDSG) search strategy. Reports that described (or might have described) randomised controlled trials of acupuncture in the treatment of endometriosis were obtained using the following strategy:

1. The MDSG specialised register of controlled trials was searched for any trials with endometriosis in the title, abstract, or keyword sections.

2. The following electronic databases were searched (from inception to December 2016): Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library), PubMed, and EMBASE.

3. Four electronic Chinese databases were examined (from inception to December 2016): the Chinese Science and Technology Journal Full-text Database (CNKI), Wanfang Data, the Chinese Biomedical Literature Database (VIP), and the China Biology Medicine (CBM) disc.

A detailed search strategy is given in S1 Appendix.

Searching other resources

We searched the bibliographies of the retrieved studies, narrative reviews, and meta-analyses to identify further relevant articles. Moreover, we contacted the authors to ask for the raw data. An additional search of conference abstracts was carried out on the ISI Web of Knowledge.

Selection criteria and exclusion criteria

Research type

We included randomised controlled trials (RCTs).

Research subjects

We recruited women of reproductive age who had a laparoscopically confirmed diagnosis of endometriosis. The exclusion criteria for individual participants were primary dysmenorrhoea (in the absence of an identifiable pathological condition) and asymptomatic endometriosis.

Interventions

Intervention groups comprised patients who had received acupuncture therapy; control groups had received sham acupuncture, Western medicine, or Traditional Chinese Medicine.

Outcomes

Variations in main pain level

Our primary treatment outcome measurement was any change in the level of pelvic pain not associated with menses or sexual activity. This outcome was assessed after 8 weeks of treatment and was based on the pain intensity question in the Endometriosis Symptom Severity Scale [ 21]. Using a numerical analogue scale, patients were asked to rate, from 0 to 10, pain severity during the previous 4 weeks that was not associated with menses or sexual activity. The Endometriosis Symptom Severity Scale has been validated and is sensitive to changes in endometriosis-associated pelvic pain in adults (not adolescents) enrolled in clinical trials [ 21].

Variation in peripheral blood CA-125 levels

Blood CA-125 levels were determined before and after treatment using an enzyme-linked immunosorbent assay.

Clinical effective rate

The overall effectiveness of acupuncture therapy was assessed subjectively and in a dichotomous manner; it was defined as the proportion of participants who experienced relief of their endometriosis-associated pain after acupuncture treatment, as indicated by the patients' responses to the evaluation criteria. Therapeutic effects were assessed in terms of the diagnosis and treatment standards for Combined Traditional Chinese and Western medicine in the treatment of endometriosis (1991) [ 22]. Patients were classified in one of four groups: (1) cured-the symptoms of dysmenorrhoea, abdominal discomfort, abdominal pain, periodic rectal irritation, etc., as well as the pelvic mass, had disappeared; (2) markedly effective-abdominal pain was obviously relieved, other symptoms had improved, and the pelvic mass had narrowed by more than 50%; (3) effective-abdominal pain was relieved, other symptoms had improved, the pelvic mass had narrowed more than 33%, and dysmenorrhoea had not increased in severity three menstrual cycles after treatment; (4) failed-abdominal pain and other symptoms had not changed. The clinical effective rate was calculated using the following equation: (number of cured + markedly effective + effective cases)/ (total number of cases).

Data extraction and quality assessment

Searches were conducted and the data were extracted by two independent researchers. Each trial identified in the search was evaluated in terms of design, eligibility criteria for participants, and outcome measures. When the researchers disagreed regarding the eligibility of a trial, they consulted a third researcher to resolve the situation. We created a form for data extraction which included (1) basic information about each trial, including the topic, first author, dateline, and journal; (2) basic information about the patients, including the number of patients in each group and their mean age; (3) the study design and intervention; and (4) the outcomes.

The quality of the trials included in this study was assessed by two other researchers in accordance with the Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0) [ 23].

Statistical analyses

All analyses were performed using comprehensive meta-analysis statistical software (RevMan 5.1.0; Cochrane Collaboration, Copenhagen, Denmark) [ 23]. Continuous outcome variables were analysed using a standardised measure; dichotomous variables were compared and the results were presented as odds ratios (ORs). To obtain the standard deviation (SD) of the change from baseline in the experimental intervention groups, we used the following equation, in which R ₁ = 0.5 [ 23]:

The term " SD(B)" represents the standard deviation before intervention, while " SD(F) " denotes the standard deviation after intervention.

We evaluated homogeneity among the trials using I ² statistics. Specifically, if I ² was ≥ 50%, the trials were considered heterogeneous, and a random-effects model based on a Mantel-Haenszel (MH) or inverse variance (IV) statistical approach was selected. If I ² was < 50%, the studies were considered homogeneous, and a fixed-effects model based on an MH or IV statistical approach was used. Pooled summary statistics of the differences in ratio or mean of the individual studies were developed. Pooled differences in ratios or means, as well as two-sided P-values, were calculated and used as criteria for determining the level of statistical significance. P-values < 0.05 were considered statistically significant. Moreover, a sensitivity analysis was conducted based on the "leave-one-out" cross-validation procedure [ 24].

Results

Study selection

A flow chart of the included and excluded studies is shown in . Database searches yielded 46 studies from PubMed, 10 from the Cochrane Central Register of Clinical Trials, 36 from Embase, 50 from CNKI, 48 from Wanfang Data, 32 from VIP, and 41 from CBM. After removal of duplicate records, 112 studies remained. Following the first review, which was based on the title, 16 studies remained, the abstracts of which were reviewed using pre-defined eligibility criteria. A total of 16 studies were then selected for full text review and data processing. During this phase, six studies were excluded. Ultimately, 10 studies, comprising 589 participants, were included in the final meta-analysis.

Characteristics of the included studies

Information regarding the included studies

The included studies comprised a total of 295 patients whose endometriosis-related pain was treated using acupuncture. A further 294 patients comprised the control group; the details of their treatment are given below. In the 10 RCTs included, the patients' age at enrolment ranged from 13 to 52 years. The interventions were all acupuncture, while the control interventions were placebo [ 25] (also called sham acupuncture), Western medicine [ 17, 19- 20, 26], and Traditional Chinese Medicine [ 18, 27- 30] (). One RCT was conducted in Boston, while the others were from China. Other details of this kind are summarised in .

Quality assessment

Clinical outcomes

Characteristics of the excluded studies

Six studies failed to meet our inclusion criteria for the following results: (1) in one RCT comparing acupuncture with drug therapy (danazol), the pain conditions were not solely related to endometriosis [ 31]; (2) one study involved surgical intervention rather than acupuncture [ 32]; (3) one study evaluated the effectiveness of moxibustion alone and point injection, rather than moxibustion as an adjunctive therapy to acupuncture [ 33]; (4) four studies compared different methods of acupuncture and lacked a placebo or biomedical group [ 34- 36].

Discussion

Meta-analysis of clinical effect

In the current study, we systematically reviewed the results of 10 RCTs comparing the outcomes of acupuncture with those of other therapies (sham acupuncture, Western medicine, or Traditional Chinese Medicine) in the treatment of endometriosis-related pain. Among the 10 RCTs included, six reported variations in main pain level, four reported variations in peripheral blood CA-125 levels, and seven reported the clinical effective rate of acupuncture as a treatment for endometriosis-related pain. In all 10 of the studies, the interventions were acupuncture, and the control interventions were placebo [ 25], Western medicine [ 17, 19- 20, 26], or Traditional Chinese Medicine. Because so few studies were included, we did not carry out a subgroup analysis.

Only one of the included RCTs [ 25] selected sham acupuncture as the control intervention; fourteen participants completed this study in accordance with the protocol. Participants in the active acupuncture group (n = 9) experienced a mean 4.8-point (SD = 2.4-point) reduction on an 11-point scale (62%) in pain after 4 weeks; this differed significantly from the control group's (n = 5) mean reduction of 1.4 points (SD = 2.1 points; P = 0.004). Reduction in pain in the acupuncture group persisted throughout the 6-month assessment. Preliminary estimates indicate that Japanese-style acupuncture may be an effective, safe, and well-tolerated adjunct therapy for endometriosis-related pelvic pain in adolescents.

Four of the included RCTs selected Western medicine as the control intervention [ 17, 19- 20, 26]. Specifically, the studies used danazol, mifepristone, or goserelin acetate, and showed that acupuncture was better than Western medicine in relieving pain and reducing the concentration of CA-125.

Five of the RCTs selected Traditional Chinese Medicine [ 17, 19- 20, 26] as the control intervention, and all showed that acupuncture is better than Traditional Chinese medicine in relieving pain. However, we must acknowledge that few properly blinded trials [ 25] have addressed this issue, and that the effects of expectation or other non-specific factors may have contributed to the benefits seen in the present study. Nonetheless, based on a single placebo-controlled study and on other studies comparing acupuncture to Western medicine and Eastern herbs, acupuncture appears to be effective in reducing pain and serum CA-125 levels in endometriosis.

Our findings were similar to those of Lund I [ 37] and Zhu X [ 38], although we considered a greater number of databases than these previous studies; we also identified more RCTs that included three outcome measures (variation in main pain level, variation in peripheral blood CA-125 level, and clinical effective rate) in our meta-analysis.

Mechanisms of acupuncture in the treatment of endometriosis-related pain

Acupuncture and analgesia

Acupuncture seems to alleviate pain by increasing pain thresholds in human subjects, and it would appear to activate analgesic brain mechanisms through the release of neurohumoral factors, including adenosine, γ-aminobutyric acid, opioid peptide, acetylcholine, nitric oxide, noradrenaline, dopamine) and others [ 39]. Specifically, electroacupuncture can lead to the production of dopamine in the adrenal medulla [ 40].

Acupuncture and endocrine function

Endometriosis is a multifactorial, oestrogen-dependent, inflammatory, gynaecological condition. Growth of the endometrial tissue depends on oestrogen. In the human body, 90% of endogenous oestrogen is produced by the granular cells and membrane cells of the ovary, which produce the hormone in response to stimulation by follicle-stimulating hormone and luteinising hormone. In addition, oestrogen may be compounded by androstenedione from the adrenal glands [ 41]. Relatedly, several studies have shown that acupuncture can suppress serum oestradiol levels [ 42]. Thus, it may inhibit the growth of the ectopic endometrium and relieve pain.

Acupuncture and immune function

Evidence suggests that endometriosis has a strong immune component [ 43- 44]. Acupuncture enhances the ability of the immune system to more actively eliminate malignant cells by increasing the ability of NK cells to kill cancer cells [ 45]. More specifically, acupuncture stimulation increases the cytotoxicity of NK cells by promoting cross-talk between the neurotransmitter network and the immune system; this cross-talk is mediated by nitric oxide, β-endorphins, and cytokines [ 46], and it is anchored by opioid and NK cell receptors.

Thus, the effect of acupuncture in the treatment of endometriosis-related pain is likely mediated by endocrine and cytokine changes, as well as by anti-inflammatory and analgesic effects.

Limitations

The limitations of this evaluation system were as follows: (1) few of the studies discussed how the sample size was estimated, and most involved small sample sizes leading to a low precision; (2) some of the studies did not adequately report allocation concealment; failure to fully implement allocation concealment may exaggerate any curative effect observed; (3) because so few studies were included, we did not carry out a subgroup analysis; (4) three of the 10 studies [ 19, 28, 29] included in the final analysis were doctoral theses published in university archives. It is important that a separate analysis be performed without these thesis dissertations, which were not published in any peer-reviewed journal. In this regard, we did run the analysis again, and the conclusions did not change. (5) The results were heterogeneous because subjective indicators were used to evaluate curative effects (pain level, clinical effective rate); (6) implementation of the blinding method is important, but the included studies did not describe the implementation of the blinding method; and (7) the study was limited to Chinese- and English-language research articles, which may have introduced selection bias. Nonetheless, the overall bias was not large, so the conclusion is reliable.

Perspectives

In future, we recommend additional, well-designed clinical trials that compare specific types of acupuncture to placebo in the treatment of endometriosis. We emphasise the importance of proper blinding and randomisation when considering other, Western treatments in clinical trials involving acupuncture.

Conclusions

Acupuncture can alleviate the pain of dysmenorrhoea and reduce peripheral blood CA-125. As a result, the therapy could be applied as a complementary treatment for endometriosis-related pain. However, few randomised, blinded clinical trials have addressed the efficacy of acupuncture in treating endometriosis-related pain. Nonetheless, the current literature consistently finds that acupuncture yields better reductions in pain and serum CA-125 levels than do control treatments, regardless of the control intervention used. To confirm this finding, additional studies with proper controls, blinding methods, and adequate sample sizes are needed.

# data[].attributes.attachment_link.title
Effects of acupuncture for the treatment of endometriosis-related pain: A systematic review and meta-analysis

# data[].attributes.attachment_link.description
Endometriosis is a chronic, oestrogen-dependent, inflammatory disease that affects 5%-15% of reproductive-age women, causing infertility and pain-specifically chronic pelvic pain, deep dyspareunia, dysmenorrhoea, dyschezia, and dysuria [ 1- 4]. It may be that endometriosis-related changes are caused by plastic changes in the peripheral and central nervous systems, and such changes may in fact predispose for other long-lasting pain conditions [ 5].

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Overview

What is endometriosis? A Mayo Clinic expert explains

Learn more about endometriosis from Megan Wasson, D.O., a minimally invasive gynecologic surgeon at Mayo Clinic.

Hi, I'm Dr. Megan Wasson, a minimally invasive gynecologic surgeon at Mayo Clinic. In this video, we will cover the basics of endometriosis, including what is it, who gets it, as well as the symptoms, diagnosis and treatment. Whether you are looking for answers for yourself or someone you love, we are here to give you the best information available. Endometriosis is a condition in which cells similar to the lining of the uterus, or endometrium, grow outside the uterus. Endometriosis often involves the pelvic tissue and can envelop the ovaries and fallopian tubes. It can affect nearby organs, including the bowel and bladder. So during the menstrual cycle, or period, this tissue responds to hormones, and due to its location, frequently results in pain. Endometriosis causes surrounding tissues to become irritated and potentially develop scars and sticky fibers that bind tissues together. In some cases, endometriosis can cause cysts on the ovaries. These are called endometriomas. Fortunately, there are effective treatments to manage and treat endometriosis.

Who gets it?

There are some possible explanations of what sparks the endometrial-like tissue to grow out of place. But the exact cause is still uncertain. However, there are some factors that make someone more likely to get endometriosis, such as never giving birth, menstrual cycles occurring more frequently than every 28 days, heavy and prolonged menstrual periods that lasts longer than seven days, having higher levels of estrogen in your body, having a low body mass index, having a structural issue with the vagina, cervix, or uterus that prevents the passage of menstrual blood from the body, a family history of endometriosis, starting your period at an early age, or starting menopause at an older age.

What are the symptoms?

The most common symptom of endometriosis is pelvic pain, either during or outside of the normal menstrual period that is beyond normal cramping, Normal menstrual cramping should be tolerable and should not require someone to miss time from school, work or normal activities. Other symptoms include cramps that begin before and extend after a menstrual period, lower back or abdominal pain, pain with intercourse, pain with bowel movements or urination, and infertility. Individuals with endometriosis may experience fatigue, constipation, bloating, or nausea, especially during periods. If you are feeling these symptoms, it's a good idea to talk to your health care provider.

How is it diagnosed?

First, your provider will ask you to describe your symptoms, including the location of the pelvic pain. Next, they may do a pelvic exam, an ultrasound, or an MRI to get a clearer view of the reproductive organs, including the uterus, ovaries, and fallopian tubes. To definitively diagnose endometriosis, surgery is required. This is most commonly performed by laparoscopy. The patient is under general anesthesia while the surgeon inserts a camera into the abdomen through a small incision to evaluate for endometrial-like tissue. Any tissue that looks like endometriosis is removed and examined under the microscope to confirm the presence or absence of endometriosis.

How is it treated?

When it comes to treating endometriosis, first steps involve trying to manage symptoms through pain medications or hormone therapy. Hormones, such as birth control pills, control the rise and fall of estrogen and progesterone in the menstrual cycle. If those initial treatments fail and symptoms are impacting a person's quality of life, surgery to remove endometriosis tissue may be considered.

What now?

Dealing with endometriosis, its pain, complications and fertility problems can be hard to cope with and be stressful. Consider joining a support group of people who can relate to what you are going through. If you'd like to learn even more about endometriosis, watch our other related videos or visit mayoclinic.org. We wish you well.

Endometriosis (en-doe-me-tree-O-sis) is an often-painful condition in which tissue that is similar to the inner lining of the uterus grows outside the uterus. It often affects the ovaries, fallopian tubes and the tissue lining the pelvis. Rarely, endometriosis growths may be found beyond the area where pelvic organs are located.

Endometriosis tissue acts as the lining inside the uterus would - it thickens, breaks down and bleeds with each menstrual cycle. But it grows in places where it doesn't belong, and it doesn't leave the body. When endometriosis involves the ovaries, cysts called endometriomas may form. Surrounding tissue can become irritated and form scar tissue. Bands of fibrous tissue called adhesions also may form. These can cause pelvic tissues and organs to stick to each other.

Endometriosis can cause pain, especially during menstrual periods. Fertility problems also may develop. But treatments can help you take charge of the condition and its complications.

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Symptoms

The main symptom of endometriosis is pelvic pain. It's often linked with menstrual periods. Although many people have cramping during their periods, those with endometriosis often describe menstrual pain that's far worse than usual. The pain also may become worse over time.

Common symptoms of endometriosis include:

Painful periods. Pelvic pain and cramping may start before a menstrual period and last for days into it. You also may have lower back and stomach pain. Another name for painful periods is dysmenorrhea.

Pain with sex. Pain during or after sex is common with endometriosis.

Pain with bowel movements or urination. You're most likely to have these symptoms before or during a menstrual period.

Excessive bleeding. Sometimes, you may have heavy menstrual periods or bleeding between periods.

Infertility. For some people, endometriosis is first found during tests for infertility treatment.

Other symptoms. You may have fatigue, diarrhea, constipation, bloating or nausea. These symptoms are more common before or during menstrual periods.

The seriousness of your pain may not be a sign of the number or extent of endometriosis growths in your body. You could have a small amount of tissue with bad pain. Or you could have lots of endometriosis tissue with little or no pain.

Still, some people with endometriosis have no symptoms. Often, they find out they have the condition when they can't get pregnant or after they get surgery for another reason.

For those with symptoms, endometriosis sometimes may seem like other conditions that can cause pelvic pain. These include pelvic inflammatory disease or ovarian cysts. Or it may be confused with irritable bowel syndrome (IBS), which causes bouts of diarrhea, constipation and stomach cramps. IBS also can happen along with endometriosis. This makes it harder for your health care team to find the exact cause of your symptoms.

When to see a doctor

See a member of your health care team if you think you might have symptoms of endometriosis.

Endometriosis can be a challenge to manage. You may be better able to take charge of the symptoms if:

Your care team finds the disease sooner rather than later.

You learn as much as you can about endometriosis.

You get treatment from a team of health care professionals from different medical fields, if needed.

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Causes

The exact cause of endometriosis isn't clear. But some possible causes include:

Retrograde menstruation. This is when menstrual blood flows back through the fallopian tubes and into the pelvic cavity instead of out of the body. The blood contains endometrial cells from the inner lining of the uterus. These cells may stick to the pelvic walls and surfaces of pelvic organs. There, they might grow and continue to thicken and bleed over the course of each menstrual cycle.

Transformed peritoneal cells. Experts suggest that hormones or immune factors might help transform cells that line the inner side of the abdomen, called peritoneal cells, into cells that are like those that line the inside of the uterus.

Embryonic cell changes. Hormones such as estrogen may transform embryonic cells - cells in the earliest stages of development - into endometrial-like cell growths during puberty.

Surgical scar complication. Endometrial cells may attach to scar tissue from a cut made during surgery to the stomach area, such as a C-section.

Endometrial cell transport. The blood vessels or tissue fluid system may move endometrial cells to other parts of the body.

Immune system condition. A problem with the immune system may make the body unable to recognize and destroy endometriosis tissue.

Risk factors

Factors that raise the risk of endometriosis include:

Never giving birth.

Starting your period at an early age.

Going through menopause at an older age.

Short menstrual cycles - for instance, less than 27 days.

Heavy menstrual periods that last longer than seven days.

Having higher levels of estrogen in your body or a greater lifetime exposure to estrogen your body produces.

Low body mass index.

One or more relatives with endometriosis, such as a mother, aunt or sister.

Any health condition that prevents blood from flowing out of the body during menstrual periods also can be an endometriosis risk factor. So can conditions of the reproductive tract.

Endometriosis symptoms often happen years after menstruation starts. The symptoms may get better for a time with pregnancy. Pain may become milder over time with menopause, unless you take estrogen therapy.

Complications

Infertility

The main complication of endometriosis is trouble getting pregnant, also called infertility. Up to half of people with endometriosis have a hard time conceiving.

For pregnancy to happen, an egg must be released from an ovary. Then the egg has to travel through the fallopian tube and become fertilized by a sperm cell. The fertilized egg then needs to attach itself to the wall of the uterus to start developing. Endometriosis may block the tube and keep the egg and sperm from uniting. But the condition also seems to affect fertility in less-direct ways. For instance, it may damage the sperm or egg.

Even so, many with mild to moderate endometriosis can still conceive and carry a pregnancy to term. Health care professionals sometimes advise those with endometriosis not to delay having children. That's because the condition may become worse with time.

Cancer

Some studies suggest that endometriosis raises the risk of ovarian cancer. But the overall lifetime risk of ovarian cancer is low to begin with. And it stays fairly low in people with endometriosis. Although rare, another type of cancer called endometriosis-associated adenocarcinoma can happen later in life in those who've had endometriosis.

Endometriosis care at Mayo Clinic

Show references

1. Endometriosis. Office on Women's Health. https://www.womenshealth.gov/publications/our-publications/fact-sheet/endometriosis.html. Accessed March 22, 2023.

2. Schenken RS. Endometriosis: Pathogenesis, epidemiology, and clinical impact. https://www.uptodate.com/contents/search. Accessed March 22, 2023.

3. FAQs: Endometriosis. American College of Obstetricians and Gynecologists. https://www.acog.org/womens-health/faqs/endometriosis. Accessed March 22, 2023.

4. AskMayoExpert. Endometriosis. Mayo Clinic; 2022.

5. Smith RP. Endometriosis. In: Netter's Obstetrics and Gynecology. 3rd ed. Elsevier; 2018. https://www.clinicalkey.com. Accessed March 22, 2023.

6. What is assisted reproductive technology? Centers for Disease Control and Prevention. https://www.cdc.gov/art/whatis.html. Accessed March 22, 2023.

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Learn about endometriosis, including possible treatments for this condition that can cause pain and sometimes infertility.

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Acupuncture is a form of treatment involving the insertion of very thin needles through a person's skin at specific, strategic points on their body. Traditional Chinese medicine considers acupuncture as a way to balance the qi (energy or life force). Western medicine considers it a method to stimulate muscles, nerves, and connective tissue.

Endometriosis

Endometriosis is a condition that occurs when the endometrium - the tissue that lines the uterus - grows outside the uterus. Endometriosis typically involves the tissue lining the pelvis, ovaries, or fallopian tubes. It rarely spreads beyond the pelvic organs and is often quite painful.

Acupuncture practitioners promote acupuncture for endometriosis as a natural, noninvasive approach that is less risky and less costly. It also has fewer side effects than the drugs and surgery recommended by conventional medicine.

One of the steps you might experience when visiting an acupuncture practitioner is a traditional Chinese medicine (TCM) diagnosis to identify your unique symptoms. This diagnosis is used to develop an individualized acupuncture treatment plan. The most common TCM imbalances (clusters of symptoms) in endometriosis include:

If you decide to try acupuncture for your endometriosis, plan for the initial course of treatment to last six to eight weeks with visits once or twice a week. After the first phase, your practitioner might move you to two weeks a month. Commonly, you would be told to expect results in three to six months.

Your acupuncture practitioner might also recommend nutritional therapy that could include herbal formulas.

There's no definitive answer to the question about acupuncture working for endometriosis. The closest answer would be that acupuncture could help some women deal with the discomfort of endometriosis, but more studies are necessary.

A 2011 article in the New England Journal of Medicine cited a trial that showed the efficacy of Japanese-style acupuncture for endometriosis-related pain. The article concluded that data from large, randomized, controlled trials is needed to confirm these findings.

A 2017 journal article indicated that, although literature suggests that pain can be reduced with acupuncture, more studies with adherence to best clinical practices are needed.

The first step your doctor might recommend is to treat your endometriosis with over-the-counter (OTC) pain medications such as NSAIDs. If that doesn't give you the results you need, your next step might be hormone therapy. This includes:

hormonal contraceptives

progestin therapy

aromatase inhibitors

Gn-RH (gonadotropin-releasing hormone) agonists and antagonists

The final step, if the first steps do not offer you the relief you need, might be surgery. Commonly, your doctor might recommend laparoscopic surgery to remove endometrial tissue. In some cases, your doctor might recommend a hysterectomy, perhaps removing of your ovaries as well.

Acupuncture is often considered a complementary medicine as opposed to an alternative one. A complementary medicine is one that works alongside other medical treatments. It doesn't replace them. Although it hasn't yet been proven, there are some indications that acupuncture could help some women with endometriosis.

To be sure of what acupuncture can and can't do to treat endometriosis, more clinical research studies are necessary.

Before making a final decision about any complementary procedure (such as acupuncture) discuss it with your doctor. There's little risk to acupuncture from a trained acupuncturist. It might be an option for those who have not found treatment from other methods.

Acupuncture isn't usually covered by insurance and typically requires numerous visits and treatments. If you're considering acupuncture, discuss costs with your practitioner before you begin your course of treatment. You should also talk to your medical provider about your use of this treatment and the results you're experiencing.

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Endometriosis occurs when the tissue that lines the uterus grows outside the uterus. Acupuncture is a form of treatment involving the insertion of very thin needles through a person's skin at specific, strategic points on their body. Many people believe that acupuncture can relieve the discomfort of endometriosis.

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Medical treatments are often used as a first line treatment to control symptoms. They are often used in conjunction with surgery. It's important to understand how medications work so you can make informed choices. There are no known medications which cure endometriosis. Here's some which are commonly used:

Pain medications work best when taken on time and before the pain gets too bad. Many are available without prescription and advice should be sought from a pharmacist to ensure the brand you are buying is going to give you the best relief. Sometimes combinations of drugs (e.g. an anti-inflammatory and pain relief preparations taken together) can be very effective but it is crucial that you seek expert advice from your doctor or specialist. You may need prescription pain medication from your doctor or specialist.

The Contraceptive Pill can help to balance and regulate periods and often eases distressing symptoms. If you choose to go on the pill, it's important to be prescribed the one that is best suited to your condition. Some oral contraceptive pills can mask symptoms but not the progression of endometriosis - this is especially important if you have NOT had a diagnosis. Depo Provera (the injection) may also be offered. Other hormone medications might be recommended. These aim to reduce the growth of endometriosis by suppressing oestrogen.

GnRH analogues such as Zoladex (subcutaneous injection) are commonly prescribed. It's important to discuss the benefits and side effects with your doctor.

Intrauterine device or system (IUS) like Mirena® (placed inside the uterus) is a contraceptive which slowly releases a hormone and lasts for about five years. It's often used to treat heavy bleeding and can lessen painful symptoms. This is sometimes fitted at the same time as laparoscopic surgery.

Natural painkillers such as magnesium can relieve pain. Follow the guidance of a medical herbalist or natural health practitioner.

Unfortunately there is no evidence that medical treatment for endometriosis improves fertility outcomes but they can improve symptoms.

More specific information on medications commonly used and the side effects can be found in the book: "Endometriosis and Pelvic Pain" or contact us. It's important to be informed about all medications.

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Endo Treatment | Treating Endometriosis | Endometriosis New Zealand

# data[].attributes.attachment_link.description
Medical treatments are often used as a first line treatment to control symptoms. They are often used in conjunction with surgery. It's important to understand how medications work so you can make informed choices. There are no known medications which cure endometriosis.