Endometriosis treatment typically starts with over-the-counter pain relief and hormonal therapy, then escalates to stronger medications or surgery depending on how well symptoms respond. There is no cure, but most people find a combination that meaningfully reduces pain and improves daily life. The right approach depends on the severity of your symptoms, whether you’re trying to conceive, and how your body responds to hormonal options.
Pain Relief as a Starting Point
Anti-inflammatory painkillers are usually the first step because they target both the pain and the underlying inflammation that endometrial-like tissue causes in the pelvis. Ibuprofen and naproxen are the most commonly recommended options. A typical starting point is 400 mg of ibuprofen three times a day, which can be increased up to 800 mg three times daily if needed. These medications work best when taken consistently rather than waiting until pain becomes severe, particularly in the days leading up to and during your period.
Pain relievers alone won’t slow the growth of endometrial tissue, so they’re usually paired with hormonal treatment unless there’s a specific reason to avoid it. If over-the-counter options aren’t enough, your doctor may add other pain-management strategies before moving to stronger prescriptions.
Hormonal Therapy: The Main Treatment
Hormonal treatments are the backbone of endometriosis management for people who aren’t actively trying to get pregnant. They work by suppressing estrogen, which fuels the growth of endometrial-like tissue, or by thinning the tissue directly. Several categories exist, and your doctor will typically start with the simplest option before moving to more targeted drugs.
Combined Birth Control Pills
Combined estrogen-progestin pills reduce menstrual flow and cause the misplaced tissue to shrink. In clinical trials, women taking these pills reported significantly less menstrual pain compared to placebo. Many doctors recommend taking the pill continuously (skipping the placebo week) to eliminate periods entirely, which removes the monthly hormonal surge that triggers flare-ups. These are often the first hormonal option because they’re well-tolerated, inexpensive, and widely available.
Progestin-Only Options
If combined pills aren’t a good fit, progestin-only treatments offer another route. Dienogest, a progestin specifically studied for endometriosis, reduced disease severity scores by roughly two-thirds at a dose of 2 mg daily in clinical trials. A hormonal IUD is another popular progestin-only choice because it delivers the hormone directly to the uterus, minimizing side effects elsewhere in the body. Progestin-only pills, injections, and implants are also used. Common side effects include irregular bleeding (especially in the first few months), bloating, and mood changes.
GnRH Antagonists
For people whose pain doesn’t respond well to birth control or progestins, a newer class of oral medications called GnRH antagonists offers more powerful suppression. These drugs dial down your body’s estrogen production to reduce pain from endometrial tissue.
Elagolix (brand name Orilissa) was the first oral GnRH antagonist approved for endometriosis. In extension trials lasting 12 months, 78% of women on the higher dose experienced meaningful relief from menstrual pain, 69% saw improvement in everyday pelvic pain, and 60% had less pain during sex. The trade-off is bone density loss: women on the higher dose lost between 5% and 15% of bone mineral density, which is why this dose is limited to six months of use.
Relugolix combination therapy (brand name Myfembree) pairs a GnRH antagonist with low-dose estrogen and progestin “add-back” to protect bones while still controlling symptoms. In clinical trials, 75% of women responded positively for menstrual pain compared to about 27-30% on placebo, and bone density changes stayed below 1% at six months. This add-back approach makes longer treatment more feasible.
GnRH Agonists
Older injectable GnRH agonists like leuprolide work by temporarily shutting down ovarian function, creating a menopause-like state. The FDA approves their use for up to six months alone. With add-back hormone therapy (a small dose of progestin to offset side effects like hot flashes and bone loss), treatment can be extended to 12 months. Add-back therapy is considered essential for anyone using these drugs beyond six months.
When Surgery Becomes the Right Option
Surgery enters the picture when medications haven’t controlled your symptoms adequately, when imaging reveals structural problems like large ovarian cysts (endometriomas), or when endometrial tissue is affecting your bowel or urinary tract. Endometriomas larger than 5 cm carry a higher risk of ovarian torsion, a painful emergency where the ovary twists on itself, which is one reason doctors may recommend removal rather than watchful waiting.
Bowel involvement that causes narrowing, or tissue compressing a ureter, typically requires a multidisciplinary surgical team. These situations are less common but represent cases where delaying surgery could lead to organ damage.
Excision vs. Ablation
Two main laparoscopic techniques exist for removing endometriosis: excision (cutting the tissue out completely) and ablation (burning or vaporizing the surface). A meta-analysis comparing the two found that excision produced significantly better results for menstrual pain, pain with bowel movements, and chronic pelvic pain at 12 months after surgery. Excision also led to meaningfully better quality-of-life scores on standardized questionnaires. Pain during sex trended better with excision too, though the difference didn’t quite reach statistical significance.
The reason excision tends to outperform ablation is straightforward: burning the surface may leave deeper tissue behind, while cutting removes the full depth of the lesion. Many endometriosis specialists now consider excision the preferred technique, though it requires more surgical skill and longer operating times.
Recurrence After Surgery
Even after thorough excision, endometriosis can come back. Published recurrence rates for deep infiltrating endometriosis range from 2% to 43%, with the wide range largely reflecting differences in how long patients were followed and how “recurrence” was defined. Longer follow-up periods naturally catch more recurrences. This is why many doctors recommend continuing hormonal therapy after surgery to suppress regrowth, particularly if you’re not trying to conceive.
For people who’ve had multiple surgeries without lasting relief, more definitive procedures like hysterectomy (with or without removal of the ovaries) may be discussed. These are typically considered a last resort because of their permanence and the implications for fertility and hormone balance.
Pelvic Floor Physical Therapy
Years of pelvic pain cause the muscles in your pelvic floor to tighten and spasm, which creates its own layer of pain on top of the endometriosis itself. Pelvic floor physical therapy addresses this directly. A 2025 meta-analysis of seven studies found that physical therapy reduced pain scores by roughly 2 points on a 10-point scale compared to non-physical-therapy approaches. Locally applied techniques, meaning hands-on work targeting specific pelvic muscles rather than general exercise, produced the greatest benefit.
Electrotherapy and laser devices showed the largest pain reductions in the analysis. Physical therapy won’t treat the endometrial tissue itself, but it can meaningfully reduce the muscle-driven component of pelvic pain that medications and surgery don’t always address. Many specialists now recommend it as part of a comprehensive treatment plan rather than a standalone option.
Diet and Lifestyle Adjustments
Dietary changes won’t replace medical treatment, but they can help manage day-to-day symptoms. Endometriosis involves chronic inflammation, so eating patterns that reduce inflammation throughout the body may lower your baseline pain level. Common dietary triggers reported by people with endometriosis include alcohol, caffeine, gluten, dairy, and high-sugar foods, though triggers vary from person to person.
The most practical approach is keeping a food journal for several weeks, noting what you eat alongside any symptom changes. Patterns tend to emerge that let you identify your specific triggers rather than following a rigid elimination diet. Omega-3-rich foods like fatty fish, walnuts, and flaxseed have anti-inflammatory properties that some people find helpful, while red meat and processed foods tend to promote inflammation. These adjustments work best as one piece of a broader treatment strategy that includes medical management.
Putting a Treatment Plan Together
Endometriosis treatment is rarely one thing. Most people end up with a combination: a hormonal method to suppress tissue growth, a pain management strategy for flare-ups, physical therapy to address muscle tension, and dietary adjustments to reduce inflammation. The mix changes over time as your symptoms shift, as you move in and out of trying to conceive, or as one approach stops working as well.
If your current treatment isn’t controlling your pain, that’s useful information rather than a dead end. Each step of the treatment ladder exists because the previous one doesn’t work for everyone, and there are more options available now than even five years ago. A specialist in endometriosis (typically a gynecologist with advanced training in minimally invasive surgery) can offer the widest range of options and the most experience tailoring treatment to individual cases.