Treating Endometriosis Pain: Medical and Supportive Options
Key Takeaways
No single ladder of treatment suits everyone with endometriosis pain. ESHRE lists painkillers, the combined pill, progestogens and GnRH medicines as options. It keeps aromatase inhibitors for pain that resists other treatment. Physiotherapy and psychological support may help some people, but neither is an established treatment for endometriosis. Pregnancy plans belong in the decision from the start.
Key evidence: ESHRE Guideline: Endometriosis (2022) Dienogest vs Leuprolide Trial (Strowitzki et al., 2010) NICE Guideline: Endometriosis Diagnosis and Management (NG73)
Why treatment needs to be individualised
Endometriosis pain has several possible contributors: inflammation, adhesions or deep disease, changes in how the nervous system processes pain, and tight pelvic floor muscles. Their weight differs from one person to another.
No single treatment covers all of them. The ESHRE 2022 guideline presents analgesics, hormonal treatment and surgery as options to choose between through shared decision-making. The choice weighs your preferences, side effects, how well each works for you, cost and availability. Care may move step by step, but there is no fixed ladder.
Four practical points usually shape the choice:
- Your pain pattern: painful periods that worsen over time, pelvic pain outside periods, deep pain during sex, or bowel and bladder pain that follows the cycle.
- Pregnancy plans: hormonal treatments that suppress ovulation are not used during active attempts to conceive.
- Tolerability: how you cope with irregular bleeding, mood changes and other side effects.
- Health history: clot risk, migraine with aura, blood pressure, smoking and bone health.
Your doctor sets the medicine, dose and length of treatment. For a broader overview, read our complete endometriosis guide, the guide to diagnosing endometriosis and the page on endometriosis symptoms.
Analgesics and combined hormonal contraceptives
Non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs such as ibuprofen or mefenamic acid are taken at the start of a painful episode. They lower prostaglandins, chemicals that make the womb contract and hurt. ESHRE says women may be offered NSAIDs or other analgesics, alone or with other treatments.
Regular or high-dose use can irritate the stomach and affect the kidneys and heart. NSAIDs also do not treat every source of pelvic pain. If pain persists, it needs reassessment rather than more tablets.
Combined hormonal contraceptives (CHC)
ESHRE 2022 strongly recommends offering a combined hormonal contraceptive (pill, patch or vaginal ring) to reduce painful periods, pain outside periods and pain during sex. For painful periods, continuous use without a monthly break can also be offered (weak recommendation).
Oestrogen-containing treatment does not suit everyone. A clinician should review any history of blood clots, migraine with aura, blood pressure, smoking and other cardiovascular risks before prescribing it.
Progestogens
Dienogest 2 mg daily
Dienogest is a progestogen taken by mouth for endometriosis pain.
A 24-week randomised trial in 252 women compared it with leuprolide acetate, a GnRH-agonist injection. Randomised means chance decided who received which treatment; open-label means everyone knew which one they were taking. Pain fell by a similar amount with both. Hot flushes and other low-oestrogen effects were reported less often with dienogest, and bleeding was suppressed less. Lumbar spine bone density changed by +0.25% with dienogest and −4.04% with leuprolide in the subgroups measured. These results apply to the treatments and the 24 weeks studied. They do not show that every progestogen equals every GnRH medicine.
Irregular bleeding or spotting is common, especially early on, and periods may stop. Some people report changes in weight or mood. Troublesome effects are worth reviewing with your doctor rather than enduring.
Other progestogen options
ESHRE strongly recommends progestogens for endometriosis pain and asks clinicians to take their different side-effect profiles into account. Options include:
- Levonorgestrel-releasing intrauterine system (LNG-IUS): the hormonal coil. It may suit someone who also wants contraception or finds daily tablets difficult.
- Etonogestrel implant: a small rod under the skin that releases progestogen continuously, without oestrogen.
- Other oral progestogens: norethisterone acetate or medroxyprogesterone acetate, chosen according to your history and tolerance.
Bleeding preferences, contraception needs and side effects decide between them.
GnRH agonists and add-back treatment
GnRH agonists (leuprolide, triptorelin, goserelin or nafarelin) temporarily switch off the ovaries’ hormone production. Oestrogen falls, and endometriosis tissue loses its stimulus. The effect is reversible. These medicines can reduce pain, but the low oestrogen may cause hot flushes, night sweats, vaginal dryness, mood changes and loss of bone density.
- Place in treatment: ESHRE advises keeping GnRH agonists for second-line use, for example when contraceptives or progestogens have not worked, because of their side effects. Evidence on dose and duration is limited.
- Add-back treatment: ESHRE strongly recommends considering combined hormonal add-back, a low dose of hormones given alongside, to prevent bone loss and low-oestrogen symptoms. The exact regimen depends on the medicine and your contraindications.
- Duration: there is no single course length. It depends on the product, your response, the add-back regimen and your risk profile.
- Bone health: a bone-density scan may be appropriate if treatment is prolonged or you have risk factors for osteoporosis.
- GnRH antagonists: ESHRE says these can be considered to reduce pain (weak recommendation), also as second-line treatment, with limited evidence on dose and duration. Availability and licensing differ between countries.
Aromatase inhibitors: a niche option
Aromatase inhibitors such as letrozole or anastrozole reduce oestrogen production. ESHRE strongly recommends them only for pain that stays refractory (resistant) to other medical or surgical treatment.
- With ovarian suppression: ESHRE says they may be combined with the contraceptive pill, a progestogen, or a GnRH agonist or antagonist.
- After menopause: a specialist may consider them, especially if surgery is not feasible (weak recommendation). Evidence is limited.
This remains off-label in many countries and belongs in complex cases under specialist supervision.
Integrative and multidisciplinary approaches
Living with persistent pain can need support beyond medication. ESHRE advises discussing non-medical strategies for quality of life and psychological wellbeing. It makes no recommendation for any specific one (Chinese medicine, nutrition, electrotherapy, acupuncture, physiotherapy, exercise or psychological interventions), because the benefits and harms are unclear.
Pelvic floor physiotherapy
Pelvic floor physiotherapy may be considered if examination suggests overactive or tender muscles, or poor coordination. A specialist physiotherapist can adapt relaxation, manual treatment or biofeedback to the findings. It targets the muscular part of the pain, not the endometriosis lesions themselves.
Cognitive behavioural therapy (CBT)
CBT may give practical tools for living with chronic pain, anxiety or poor sleep. It can sit alongside medical care, but the evidence does not support presenting it as a specific endometriosis treatment.
Acupuncture
Evidence for acupuncture is limited and does not support calling it a standard treatment. If you choose it, keep it as an extra and do not let it delay medical assessment.
Nutrition and dietary patterns
No specific diet has been shown to treat endometriosis lesions or pain. A balanced diet may support general health and digestive comfort. Discuss supplements in light of your diet, any documented deficiency and possible interactions. They do not replace medical care.
Special case: adolescents
Symptoms can begin around the first periods. A normal ultrasound does not rule out endometriosis, particularly superficial disease (ESHRE 2022). NICE NG73 likewise advises not to exclude it when examination and scan are normal, so persistent symptoms still deserve assessment. ESHRE says clinicians may consider endometriosis in a young woman who repeatedly misses school because of her periods, or who uses the contraceptive pill for painful periods (weak recommendation).
For adolescents, ESHRE 2022 advises:
- First-line hormone treatment: hormonal contraceptives or progestogens, by mouth or as a hormonal coil (strong recommendation). Some progestogens may lower bone density. NSAIDs can be used too, especially when hormones are not an option.
- If these fail in confirmed endometriosis: a GnRH agonist with add-back treatment for up to one year may be considered (weak recommendation). This should follow careful discussion of side effects and long-term risks, in specialist care.
- Laparoscopy: if imaging is negative and NSAIDs or hormones have not worked, diagnostic laparoscopy may be considered (weak recommendation). Teenagers should also be told that ovarian endometriosis and its surgery can affect ovarian reserve and later fertility.
Psychological, school and family support can help with pain that starts early in life, although ESHRE makes no recommendation for a specific non-medical intervention.
When to get medical help
Most endometriosis pain calls for a planned review, not an emergency visit. The NHS advises seeing a GP when symptoms affect everyday life, work or relationships, or when treatment has not helped or symptoms get worse.
Some symptoms need urgent help. The NHS advises calling emergency services (999 in the UK) or going to A&E for abdominal pain that starts suddenly and is severe. If you use an oestrogen-containing treatment (the combined pill, patch or ring), the NHS gives the same advice for pain and swelling in a leg together with shortness of breath or chest pain, which may be a deep vein thrombosis (a blood clot in a leg vein).
Dr. Aksoy’s clinical perspective
Dr. Aksoy’s Approach: Balancing Pain Relief with Fertility Goals
“When treating disabling endometriosis pain, pain intensity is not the only factor that guides the plan. I also look closely at possible organ involvement and the timing of pregnancy plans.
Hormonal treatments that suppress ovulation—including combined contraceptives, dienogest and GnRH agonists—are not used while a patient is actively trying to conceive. That timing changes the conversation.
If pregnancy is the immediate goal, we discuss a fertility assessment suited to the couple’s age, history and how long they have been trying. The next step may involve expectant management, surgery or assisted conception; it is not automatically the same for everyone. Hormonal treatment alone does not improve spontaneous pregnancy rates while someone is trying to conceive.
If pregnancy is not planned in the near term, medical options can be adjusted according to response and preference. Pelvic floor physiotherapy may be useful when examination identifies a muscular component. If a GnRH agonist is needed, add-back treatment should be discussed from the start according to the medicine and the patient’s risk profile.
Surgery is not an automatic first step for pain. It should be discussed when symptoms persist, deep disease affects an organ, or fertility considerations change the balance, with the benefits, risks and alternatives made clear.”
— Dr. Senai Aksoy
Frequently Asked Questions for Dr. Aksoy
What is your first-choice treatment for endometriosis pain, and how do you choose?
When choosing treatment for endometriosis pain I look first at how severe the pain is, how much it affects daily life, how widespread the disease is and whether the woman wants a pregnancy. If pregnancy is not planned soon, my first choice is usually hormonal treatment. Continuous combined contraceptive pills, or progestins such as dienogest, control pain in many patients. Which one I pick depends on her bleeding pattern, other illnesses, side effects and earlier treatment experience. Short courses of painkillers can be added when needed.
If there is deep endometriosis, lesions affecting the bowel or urinary tract, or severe pain that continues despite treatment, I also consider surgery. I stress one thing in particular: the aim in endometriosis is not just to suppress pain for a while, but to protect long-term quality of life and avoid unnecessary operations.
If I have irregular bleeding, weight change or mood problems on dienogest, when do you change the medicine?
I tell patients on dienogest at the start that irregular bleeding or spotting can occur in the first months. This is a common side effect in the first 2–3 months, and in most patients it can lessen with time. So I do not change the medicine at once for light spotting.
If, after three months, bleeding that affects daily life continues, becomes heavier or anaemia develops, I look for other causes and review the treatment. I do not put every weight change down to the medicine; I check whether there is a real increase and what else may explain it. I take mood changes especially seriously: if marked depressive symptoms appear, I do not wait for the three months to finish. In the end, if a treatment relieves pain but seriously harms quality of life in another way, there is no point in insisting on it.
When do you move to GnRH agonist injections? How do you plan add-back treatment and bone density follow-up?
I do not usually use GnRH agonist injections as the first option for endometriosis pain. I bring them up when contraceptive pills or progestins have not given enough response, or cannot be used. Because these medicines lower oestrogen markedly, they can cause menopause-like effects such as hot flushes, vaginal dryness and lower bone density.
So, in suitable patients, I prefer to plan add-back treatment from the start alongside the GnRH agonist: low-dose oestrogen and progestin, to reduce bone loss and other side effects. I limit the length of treatment according to the medicine and the patient’s risks.
For bone health, I ask for a bone density measurement at the start in women who have had a fracture, who are at risk of osteoporosis or who will have long or repeated suppression. When needed I do follow-up measurements, and I also review vitamin D and calcium intake and exercise habits. My aim is to control pain while protecting the patient from the long-term harms of treatment.
FAQ: more questions about endometriosis pain treatment
Can I become pregnant while taking medical treatment for endometriosis?
Hormonal treatments that suppress ovulation are not used during active attempts to conceive, and ESHRE says ovarian suppression should not be prescribed to improve fertility. If pregnancy is your goal, ask your clinician when and how to stop or change treatment instead of stopping alone. NICE states that hormonal treatment has no permanent negative effect on later fertility (recommendation 1.4.5).
Can diet alone cure endometriosis pain?
No. ESHRE makes no recommendation for any specific diet, and none has been shown to remove endometriosis lesions or replace medical treatment. A balanced diet may support general health and digestive comfort.
What happens if medical therapies fail?
If medicine does not give acceptable relief, a specialist can revisit the diagnosis and discuss other options, including laparoscopy. The decision depends on your symptoms, where the disease is, pregnancy plans, surgical risks and the alternatives. Our guide to endometriosis surgery explains what surgery can and cannot offer, and endometriosis and infertility covers pregnancy planning.
Sources
- Becker CM, Bokor A, Heikinheimo O, et al. ESHRE guideline: endometriosis. Human Reproduction Open 2022;2022(2):hoac009. PMID 35350465. doi:10.1093/hropen/hoac009.
- Strowitzki T, Marr J, Gerlinger C, et al. Dienogest is as effective as leuprolide acetate in treating the painful symptoms of endometriosis: a 24-week, randomized, multicentre, open-label trial. Hum Reprod 2010;25(3):633–641. PMID 20089522. doi:10.1093/humrep/dep469.
- National Institute for Health and Care Excellence (NICE). Endometriosis: diagnosis and management (NG73). Updated 2024.
- NHS. Endometriosis (section “See a GP if”). Accessed 6 November 2026.
- NHS. Stomach ache and abdominal pain (urgent advice). Page last reviewed 20 October 2026.
- NHS. Deep vein thrombosis (DVT) (urgent advice; risk factors). Page last reviewed 30 April 2026.
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The content has been created by Dr. Senai Aksoy and medically approved.