Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Medical treatment of endometriosis
Obstetrics and gynaecology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Do not medicate past an acute complication
Sudden severe pain, collapse, peritonism, pregnancy-related pain, bowel obstruction, heavy bleeding, fever, hydronephrosis or renal impairment requires urgent diagnostic assessment rather than escalation of routine analgesic or hormonal treatment.
Action: Check observations and pregnancy status, investigate the acute differential and involve emergency gynaecology, surgery or urology as indicated; withhold contraindicated medicines and stabilise the patient before returning to long-term symptom control.
Purpose and principles
Select safe, goal-concordant analgesic and hormonal treatment for suspected or confirmed endometriosis, monitor effectiveness and harms, and know when specialist escalation is needed.
Treatment begins with the person's current goal. Some want contraception and suppression, some need pain control without hormonal exposure, some are trying to conceive and some need organ-protective treatment for deep disease. Symptoms, anatomy and fertility priorities can change, so no medicine is universally best. Give information about expected benefit, bleeding change, time to response, adverse effects, contraceptive status and what happens after stopping, then agree a measurable goal such as fewer missed days, improved sleep or tolerable sex.
Analgesia supports but does not diagnose. NICE advises considering a short trial of paracetamol or a non-steroidal anti-inflammatory drug, alone or combined, for endometriosis-related pain. NSAIDs are often most useful when started around predictable inflammatory menstrual pain, but gastrointestinal ulceration, renal injury, asthma sensitivity, cardiovascular risk, anticoagulation and pregnancy modify safety. Persistent daily opioid escalation is poorly suited to long-term pelvic pain because tolerance, dependence, constipation and opioid-induced hyperalgesia can worsen function and bowel symptoms.
Indications, selection and cautions
Analgesia candidate
Predictable inflammatory menstrual pain without NSAID contraindication may respond to a short, correctly timed trial while investigation and longer-term planning continue.
Combined-hormone candidate
A person wanting contraception and cycle suppression without major oestrogen contraindications may choose combined hormonal contraception after an individual risk review.
Progestogen candidate
Progestogen treatment can suit those avoiding oestrogen, but bleeding pattern, mood, bone health, contraceptive licence and route require product-specific counselling.
Specialist antagonist candidate
Persistent symptoms after prior medical or surgical treatment may fit NICE-funded oral GnRH-antagonist options when pregnancy, bone, thrombotic and hormone-sensitive risks are acceptable.
Fertility-priority patient
Someone actively trying to conceive should not receive suppressive hormones to improve pregnancy rates; coordinate fertility assessment and disease management instead.
Red flags requiring action
A positive pregnancy test with pelvic pain or bleeding requires ectopic-pregnancy assessment; hormonal suppression must not be used as a substitute for locating the pregnancy.
Acute unilateral pain with vomiting or a known endometrioma raises torsion or cyst rupture and needs urgent gynaecology review even during established medical treatment.
Assessment before treatment
01Pregnancy assessmentFirst step
Why
Exclude pregnancy before starting hormonal suppression or a GnRH regimen and investigate pregnancy-related pain promptly.
Interpretation and limitations
Use timing and pregnancy potential rather than assumptions. A positive test redirects care; no endometriosis medicine treats ectopic pregnancy or miscarriage.
02Medical eligibility and medicine reconciliation
Why
Identify migraine, thrombosis, blood pressure, smoking, liver disease, cancer history, osteoporosis, interacting medicines and contraceptive needs.
Interpretation and limitations
The safe option depends on the exact product. Do not transfer eligibility from a progestogen-only medicine to an oestrogen-containing combination or vice versa.
03Pelvic imaging and referral review
Why
Check whether endometrioma, deep disease, ureteric obstruction, adenomyosis or another diagnosis requires more than symptom suppression.
Interpretation and limitations
Medical treatment may start during investigation, but organ-threatening or specialist anatomy must not be masked by temporary pain improvement.
04Bone-health assessment and DXA
Why
Estimate baseline and treatment-related bone loss before and during prolonged hypo-oestrogenic therapy.
Interpretation and limitations
Treatment approach
01Initial symptom treatmentStart a goal-matched therapeutic trialFirst stepEndometriosis is suspected or confirmed and acute complications have been excluded.+
1Discuss a short paracetamol or NSAID trial and offer combined hormonal contraception or a progestogen according to preference, fertility plans and medical eligibility.
2Explain the expected bleeding pattern, contraceptive status, common adverse effects, off-label status where relevant and the time and outcome used to judge benefit.
3Arrange ultrasound, referral or organ-specific investigation in parallel when indicated; symptom treatment must not become a barrier to diagnosis.
02Review non-responseCheck fit before changing classPain, bleeding or function remains unacceptable after an adequate and tolerated treatment trial.+
1Confirm adherence, duration, administration, interacting medicines and which symptom domains did or did not change.
Regimens, contraindications and interactions
A time-limited NSAID option for inflammatory dysmenorrhoea or pelvic pain while diagnostic and longer-term management proceeds.
Ibuprofen
Take 400 mg orally up to three times daily, at least 4 hours apart and preferably with or after food, using the lowest effective dose for the shortest necessary time.
Avoid with previous NSAID hypersensitivity, active ulcer or bleeding, severe renal, hepatic or heart failure. In pregnancy, avoid systemic NSAIDs from 20 weeks unless clinically required; if needed, use the lowest dose for the shortest time and consider antenatal monitoring after exposure for several days. They are contraindicated from 28 weeks. Review asthma, anticoagulants, cardiovascular risk, cumulative over-the-counter use and use while trying to conceive.
A licensed continuous progestogen treatment for endometriosis-associated symptoms when its bleeding and safety profile is acceptable.
Dienogest 2 mg
Take 2 mg orally once daily at about the same time without a tablet-free interval; begin the next pack immediately and continue regardless of vaginal bleeding.
Exclude pregnancy and stop hormonal contraception before initiation; dienogest is not a contraceptive, so use a non-hormonal method if needed. Review unexplained bleeding, active thrombosis, severe liver disease, hormone-dependent malignancy, mood change and bone risks.
A NICE-recommended option within its licence for adults of reproductive age with endometriosis symptoms after previous medical or surgical treatment.
Agree a review interval and record change in dysmenorrhoea, non-menstrual pain, dyspareunia, bowel or bladder pain, bleeding, sleep and daily participation.
Check blood pressure and new thrombotic, neurological, hepatic, bleeding or mood symptoms with oestrogen-containing or specialist hormonal regimens.
Monitor adherence and contraception accurately: dienogest and linzagolix are not contraceptives, while relugolix combination protection depends on correct use and initial non-hormonal cover.
Follow regimen-specific bone-health requirements, including baseline DXA for risk factors and repeat assessment after 1 year for prolonged relugolix combination or linzagolix treatment.
Reassess diagnosis, imaging and referral if an adequate trial fails or new organ-specific symptoms appear instead of moving indefinitely through suppressive medicines.
Special situations
Clinical treatment can precede surgery
NICE explicitly allows hormonal treatment for suspected disease, so requiring operative proof before symptom relief introduces avoidable delay and risk.
Contraceptive status differs
A medicine that suppresses ovarian function or bleeding is not automatically licensed or reliable contraception; check the exact product information and missed-dose rules.
Add-back is part of the regimen
For linzagolix endometriosis treatment the estradiol–norethisterone add-back is taken daily, while relugolix combination therapy already contains both hormones in one tablet.
Fertility reassurance needs timing
Suppression has no permanent adverse effect on later fertility, yet it delays conception while taken and does not improve spontaneous pregnancy rates during active attempts.
Response does not prove anatomy
Improvement with hormonal suppression supports a hormone-responsive pain mechanism but neither proves endometriosis nor excludes adenomyosis or other contributors.
Common pitfalls
01
Withholding hormonal treatment until laparoscopy confirms endometriosis.
02
Prescribing an oestrogen-containing option without checking migraine aura, thrombotic risk, blood pressure, liver disease and smoking context.
03
Describing dienogest or linzagolix as reliable contraception because they suppress symptoms or ovulation-related pathways.
04
Using relugolix combination therapy or linzagolix as an unmonitored routine initial prescription despite their licensed post-treatment position and specialist safety needs.
05
Continuing hormonal suppression when active conception is the goal in the belief that it improves spontaneous pregnancy rates.
06
Escalating analgesics without reassessing deep disease, ovarian pathology, pelvic-floor dysfunction, medicine harm and the person's functional goals.
Practice
Two practice questions
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Question 1 of 2
0 correct
Obstetrics and gynaecologyOriginal SBA
Treatment before operative confirmation
A 26-year-old has disabling cyclical pelvic pain and deep dyspareunia. Examination is normal and ultrasound is pending. She does not currently want pregnancy and has no identified hormonal contraindication. What is an appropriate next treatment step?
Sources and review status8 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Hormonal suppression reduces cyclic ovarian stimulation and may reduce dysmenorrhoea and non-menstrual pelvic pain. NICE recommends offering a combined oral contraceptive or a progestogen to people with suspected, confirmed or recurrent disease. Options include tailored or continuous combined hormonal contraception where eligible, progestogen-only tablets, depot or implant contraception, a levonorgestrel intrauterine system and licensed oral dienogest. Some uses are off label, and counselling must distinguish evidence for pain from the product's contraceptive licence.
Choice is individual. Oestrogen-containing contraception is unsuitable with important thrombotic risk, migraine with aura and several cardiovascular or hepatic conditions. Progestogens commonly alter bleeding and may affect mood, skin or weight perception; depot medroxyprogesterone has specific bone-health and delayed-fertility-return considerations. A levonorgestrel intrauterine system can support bleeding and pain control but insertion acceptability, cavity anatomy, infection and pregnancy exclusion matter. Dienogest is licensed for endometriosis but is not a contraceptive, so its product information advises non-hormonal contraception if needed.
Specialist hypo-oestrogenic treatments include GnRH agonists and oral antagonists. Agonists can initially flare symptoms and generally need time-limited use with consideration of add-back therapy. In England, NICE TA1057 recommends relugolix–estradiol–norethisterone and TA1067 recommends linzagolix with hormonal add-back, within their marketing authorisations, for adults of reproductive age who have already had medical or surgical treatment. Both require pregnancy exclusion, careful contraindication review and bone-health monitoring; their embedded or separate add-back hormones have their own thrombotic and hormone-sensitive-disease cautions.
Relugolix combination therapy is one daily tablet containing relugolix 40 mg, estradiol 1 mg and norethisterone acetate 0.5 mg. Start within 5 days after menstrual bleeding begins, stop hormonal contraception and use a non-hormonal method for at least the first month; the product provides adequate contraception after at least a month when taken correctly, but missed consecutive doses can reduce protection. It is contraindicated in pregnancy, breastfeeding, known osteoporosis, unexplained genital bleeding, important thrombotic disease, migraine with aura, severe active hepatic disease and hormone-sensitive malignancy.
Linzagolix for endometriosis is 200 mg once daily with daily add-back estradiol 1 mg and norethisterone acetate 0.5 mg. It should preferably start in the first week of the cycle, after pregnancy has been excluded, and treatment is initiated and supervised by an experienced clinician. It is not a contraceptive: use non-hormonal contraception. Assess osteoporosis risks, obtain pre-treatment DXA when risks are present and repeat after 1 year for all users, with continued monitoring thereafter when treatment continues.
Medical suppression does not improve spontaneous pregnancy rates while someone is trying to conceive. NICE therefore advises against hormonal treatment alone or combined with surgery for that purpose, and the person should move to fertility-informed assessment or operative discussion rather than losing time on suppressive therapy. Conversely, reassure someone planning pregnancy later that appropriate hormonal treatment does not permanently damage subsequent fertility. After surgery, hormonal treatment can be considered to prolong symptom benefit when immediate conception is not the goal.
Non-response is information, not failure by the patient. Confirm that dose, duration, adherence and diagnosis were adequate; ask which pain domain changed and whether adverse bleeding or mood effects outweigh benefit. Reconsider deep disease, adenomyosis, pelvic-floor overactivity, bladder or bowel disorders, neuropathic pain and sensitisation. Refer rather than rotating indefinitely through similar products when symptoms remain severe, daily life is affected, an endometrioma or organ involvement is suspected, or treatment risk has become complex.
Key points
Medical treatment aims to reduce pain and functional disruption; it suppresses disease activity while taken but does not remove lesions or guarantee permanent symptom resolution.
NICE supports a short trial of paracetamol or an NSAID, alone or together, for endometriosis-related pain, with contraindications, cumulative exposure and the person's priorities reviewed.
Offer hormonal treatment, such as a combined oral contraceptive or a progestogen, for suspected, confirmed or recurrent endometriosis; laparoscopic confirmation is not required before a therapeutic trial.
Explain that hormonal treatment can reduce pain and has no permanent adverse effect on later fertility, but most suppressive options prevent conception while used and do not improve spontaneous pregnancy rates when someone is actively trying to conceive.
Match the option to bleeding preference, contraceptive need, adherence, migraine, thrombosis risk, bone health, mood, liver disease, breastfeeding and past response rather than ranking every product identically.
NICE recommends relugolix combination therapy and linzagolix with hormonal add-back as options within their licences after previous medical or surgical treatment; these are specialist regimens, not routine first prescriptions.
Visible haematuria, flank pain, hydronephrosis or impaired renal function suggests urinary-tract involvement and needs specialist organ-protective assessment.
New focal neurological symptoms, severe depression, suicidal thinking or major deterioration temporally related to a medicine requires prompt safety review and appropriate escalation.
Chest pain, breathlessness, unilateral leg swelling or a new focal neurological deficit while taking oestrogen-containing treatment may represent thrombosis and requires emergency assessment.
Known osteoporosis can contraindicate treatment. For relugolix combination therapy and linzagolix, follow the product-specific pre-treatment risk and 1-year DXA recommendations.
05Symptom, bleeding and function baseline
Why
Define what each treatment trial is intended to change and record adverse-effect-sensitive domains.
Interpretation and limitations
Separate dysmenorrhoea, non-menstrual pain, dyspareunia, bowel and bladder pain, bleeding, mood and daily function so partial benefit is visible.
2
Reassess the diagnosis and look for endometrioma, deep disease, adenomyosis, pelvic-floor overactivity, bowel, bladder and neuropathic contributors.
3Refer to gynaecology or a specialist endometriosis service as anatomy and severity indicate, comparing another hormonal class, surgery and multidisciplinary pain care.
03GnRH escalationUse specialist suppression with safety controlsEscalationSymptoms persist after previous medical or surgical treatment and a GnRH agonist or NICE-recommended antagonist is being considered.+
1Exclude pregnancy, review bone and thrombotic risk, migraine, hepatic disease, unexplained bleeding, hormone-sensitive malignancy, contraception and all concomitant hormones.
2Use the exact licensed regimen or specialist protocol with add-back therapy where required and document DXA, blood pressure and review responsibilities.
3Stop and investigate suspected thrombosis, pregnancy, major mood change, liver injury, severe bleeding or intolerable hypo-oestrogenic effects; do not simply add another hormonal product.
04Trying to conceiveAvoid ineffective suppressive delayThe immediate priority is spontaneous pregnancy or fertility treatment rather than contraception and symptom suppression.+
1Explain that hormonal suppression prevents conception while used and does not increase spontaneous pregnancy rates in endometriosis.
2Coordinate fertility investigations and specialist discussion of operative options, ovarian reserve, tubal factors, semen assessment and assisted reproduction as appropriate.
3Use non-suppressive pain strategies compatible with possible pregnancy and agree how symptoms will be managed while fertility treatment proceeds.
Take one combination tablet orally once daily at about the same time, starting within 5 days of menstrual bleeding onset and continuing without a break under specialist supervision.
Exclude pregnancy; do not combine with hormonal contraception. It is contraindicated with known osteoporosis, current or previous venous or arterial thrombosis, migraine with aura, severe active liver disease, hormone-sensitive malignancy, unexplained genital bleeding, pregnancy or breastfeeding; follow blood-pressure, DXA and missed-dose contraceptive instructions.
A NICE-recommended licensed specialist option for symptomatic endometriosis after previous medical or surgical treatment.
Linzagolix 200 mg with hormonal add-back
Take linzagolix 200 mg orally once daily continuously with estradiol 1 mg plus norethisterone acetate 0.5 mg orally once daily, preferably starting in the first week of the menstrual cycle.
Exclude pregnancy and use non-hormonal contraception because linzagolix is not contraceptive. Screen osteoporosis and add-back contraindications, arrange DXA before treatment when bone-loss risks exist and after 1 year for all users, and review liver disease, unexplained bleeding and thrombotic risk.
JurisdictionUnited Kingdom
GnRH agonists and antagonists reduce ovarian hormone signalling and can cause vasomotor symptoms and bone loss; add-back therapy, contraindication screening and bone-density monitoring are regimen-specific safety requirements.
Review each trial at an agreed interval for pain domains, bleeding, function, adverse effects and adherence; refer when treatment is ineffective, not tolerated, contraindicated or when endometrioma, deep disease, organ risk or fertility complexity is present.