Endometriosis treatment centers on two goals: reducing pain and preserving or improving fertility. The right approach depends on how severe your symptoms are, whether you want to become pregnant, and how your body responds to initial treatments. Most people start with hormonal medications and move toward surgery only when those aren’t enough, though some cases call for both.
Hormonal Medications as First-Line Treatment
Hormonal treatments work by suppressing ovulation and menstruation, which starves endometrial implants of the hormonal signals that cause them to grow, bleed, and inflame surrounding tissue. The two most common options are combined oral contraceptive pills (estrogen plus progestin) and progestin-only treatments, which include pills, injections, and hormonal IUDs.
A recent meta-analysis comparing these two approaches found no significant differences in their ability to reduce pelvic pain, painful periods, pain during sex, or psychological well-being. Their side effect profiles were also comparable. This means the choice between them often comes down to personal preference, how you tolerate specific side effects, and whether you have any contraindications to estrogen (like a history of blood clots or migraines with aura). Many doctors start with a continuous oral contraceptive, skipping the placebo week so you don’t have a monthly bleed, since that withdrawal bleeding can trigger pain flares.
GnRH Medications for Moderate to Severe Pain
When standard hormonal options aren’t enough, a class of drugs called GnRH antagonists offers stronger suppression. These medications dramatically lower estrogen levels, effectively putting your body into a temporary, reversible menopause-like state. To counteract the hot flashes, mood changes, and bone loss that come with very low estrogen, newer formulations combine the GnRH blocker with small amounts of estrogen and progestin in a single daily pill. This “add-back” component keeps estrogen high enough to protect your bones and reduce side effects while still keeping it low enough to suppress endometriosis growth.
The FDA limits treatment with these combination tablets to 24 months because of the risk of bone loss that may not fully reverse. If you’re prescribed one, your doctor will typically order a bone density scan before you start and repeat it annually while you’re on the medication. If bone loss becomes concerning, the treatment may need to stop early. For older GnRH agonists (injections given monthly or every three months), add-back therapy using a progestin alone can effectively eliminate bone density loss during 12 months of treatment.
Surgery: Excision vs. Ablation
Surgery becomes an option when medications don’t control your symptoms, when imaging reveals large endometriotic cysts on the ovaries, or when you need a definitive diagnosis (since endometriosis can only be confirmed by looking at tissue under a microscope). Nearly all endometriosis surgery today is done laparoscopically, through small incisions using a camera and thin instruments.
The two main surgical techniques are excision, which cuts out endometrial implants and cysts entirely, and ablation, which burns or vaporizes them on the surface. The distinction matters. For ovarian endometriotic cysts, research shows that cyst recurrence is roughly twice as likely after ablation (about 27%) compared to excision (about 13%). Excision removes the cyst wall itself, while ablation only destroys the inner lining and leaves the shell behind, which can refill. Many endometriosis specialists strongly favor excision for this reason, though it requires more surgical skill and takes longer.
After surgery, many doctors recommend starting or continuing hormonal treatment to reduce the chance of recurrence. Without post-operative suppression, endometriosis symptoms return in a significant number of patients within a few years.
How Surgery Affects Fertility
If you’re planning to get pregnant, the relationship between surgery and fertility is complicated. Removing endometriotic cysts from the ovaries can improve your chances of conceiving naturally, but it also damages healthy ovarian tissue in the process. One study found that a key marker of ovarian reserve dropped by about 40% in women who had surgery on one ovary and by 57% in women who had surgery on both ovaries, measured 9 to 12 months after the procedure.
This doesn’t necessarily mean lower pregnancy rates. Research shows that fertilization rates, implantation rates, and cumulative live birth rates through IVF are comparable between women who’ve had surgery and those who haven’t. The main difference is that fewer eggs are retrieved after surgery, which can mean fewer embryos to work with. For women with endometriosis who aren’t ready to conceive yet, some reproductive specialists recommend freezing eggs before any ovarian surgery to preserve options. It’s also worth noting that ovarian reserve can decline on its own in women with endometriosis, even without surgery, and hormonal suppression doesn’t appear to prevent that natural decline.
Pelvic Floor Physical Therapy
Endometriosis doesn’t just affect the implants themselves. Years of chronic pelvic pain can cause the muscles of your pelvic floor to tighten, spasm, and develop trigger points, creating a secondary source of pain that persists even after the endometriosis is treated. Pelvic floor physical therapy targets this muscular component through internal and external manual therapy, stretching, breathing techniques, and relaxation exercises.
A case series at a tertiary hospital found that patients with biopsy-confirmed endometriosis who underwent pelvic floor physical therapy achieved a median functional improvement of 6 points on a standardized scale, which is considered the threshold for a clinically meaningful difference. This type of therapy works best as a complement to medical or surgical treatment, not a replacement. If you’ve had surgery or started hormones but still have lingering pelvic pain, pelvic floor dysfunction is worth investigating.
Non-Hormonal Treatments on the Horizon
One of the biggest frustrations with current endometriosis treatment is that nearly every effective option is hormonal, which means side effects like mood changes, weight fluctuations, low libido, and the inability to get pregnant while on treatment. Several non-hormonal drugs are now in late-phase clinical trials.
One approach targets blood vessel growth. Endometrial implants need their own blood supply to survive, and a drug originally used for other conditions is being tested for its ability to cut off that supply. CBD-based therapies are also in double-blind trials, working on pain pathways by reducing peripheral inflammation and dampening pain signaling in the central nervous system. A third candidate resets the abnormal energy metabolism of endometrial cells, essentially correcting the way these cells fuel their own growth. None of these are available yet as approved endometriosis treatments, but they represent a real shift toward options that don’t require suppressing your reproductive hormones.
Building a Treatment Plan That Works
Endometriosis is a chronic condition, and treatment is rarely one-and-done. Most people cycle through several approaches over the years as their symptoms, life circumstances, and reproductive goals change. Someone in their early twenties might start with a hormonal IUD, switch to excision surgery before trying to conceive, use IVF if needed, and then return to hormonal suppression afterward.
The most effective plans tend to combine multiple strategies: hormonal suppression to quiet the disease, surgery when specific lesions or cysts cause problems, physical therapy to address muscular pain, and lifestyle adjustments like regular exercise and anti-inflammatory nutrition to manage baseline inflammation. Tracking your symptoms in detail, including where the pain is, when it occurs in your cycle, and what makes it better or worse, gives you and your care team the information needed to adjust your approach over time.