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Alternatives to Surgery – Non-surgical options

For patients with endometriosis, there are several non-surgical options that can be explored.  Just as is the case with surgical options, there is no guarantee that the below-listed alternatives to surgery will be safe or effective for you. For example, for women who smoke or are otherwise at greater risk for stroke, birth control pills may be contraindicated. However, just as a general guideline, below we’ve listed some of the most common non-surgical strategies available for patients with endometriosis and/or fertility concerns:

Acupuncture/acupressure is one of the most popular alternative therapies for relieving pain symptoms and reducing stress.  While most studies are either inconclusive or show no benefit, some of our patients report that they experience moderate pain relief.  However, other patients find the needles uncomfortable and experience no relief from symptoms. Acupuncture can also be expensive.

Birth Control Pills (bcp’s)
1) Combined low estrogen-progestin
: Yaz and Yasman are examples of low estrogen bcp’s.
Benefits: In patients with mild to moderate endometriosis symptoms, certain types of bcp’s have proven to be fairly effective for some women. Other benefits that some women experience include a reduction in acne, reduced duration and volume of menstruation, and a more regulated menstrual cycle when taken as prescribed. Continuous use bcp stops periods completely, which may be helpful in reducing the symptoms of endometriosis, especially in teenagers. As a contraceptive, the bcp is also one of the most effective options available.
Risks: The list of potential unwanted side effects and potentially life-threatening conditions is legion and long. Although rare, birth control pills have been associated with increased risk of life-threatening conditions, including strokes, deep vein thrombosis/blood clots, and heart conditions.  Less severe potential side effects that patients have reported include weight gain, hair loss, thinning of the uterine epithelium, vaginal dryness, reduced libido, breakthrough bleeding, migraine headaches, and nausea, just to name some of the most commonly cited. This is not a comprehensive list. For a complete list of potential side-effects, or if you have any concerns, please be sure to ask one of our doctors, or review the written information provided in each birth control packet. Dr. Nezhat will review your overall health history, take into consideration your goals, and listen to your concerns before prescribing bcp’s. Before taking bcp’s, tell your doctor if you have diabetes, heart disease, a previous heart attack or stroke, or any cardiovascular risk factors like high blood pressure, high cholesterol, or cigarette smoking.

2) Progestin only bcp’s: Common brand names include Norplant, Errin, and Jadelle. The intrauterine devise called Mirena is another example, while Depo-Provera is an example of a high dose progestin-only contraceptive. Norethindrone, which is the form of progestin used in the brand name Errin, is one of the most effective progestin-only bcp’s for treating the symptoms of endometriosis and fibroids.  Progestin (or progestogen) only contraceptive pills are those that contain, as the name suggests, progestin only, with no estrogen. There are 8 types of progestins that are used in bcp’s. Therefore, be sure to talk to your doctor about the various options. These types of bcp’s are offered in low, medium, and high dose formulations. They work mainly by causing changes to the uterine lining and increasing the cervical mucus. The increased cervical mucus reduces the sperm’s ability to reach the uterus, while the changes in the uterine lining make it more difficult for a fertilized egg to implant into the uterus.
Benefits: With their lack of estrogen, progestin-only bcp’s are often a better choice for reducing symptoms in women with both endometriosis and fibroids. They are also associated with lower risks of deep vein thrombosis (DVT) and heart disease. As well, they are safer for breastfeeding mothers to take because they do not interfere with breast milk production.  As well, weight gain is less common with progestin-only pills.
Risks: Unlike estrogen-progestin combination contraceptive pills, the low dose progestin-only formulations do not consistently inhibit ovulation and so are therefore considered less reliable as contraceptives.  Another downside is that progestin-only pills have to be taken at almost the exact same time of day each day. Many women find this to be a difficult regimen to follow. Menstruation also tends to be more irregular with this form of contraceptive pill.  Other women experience more mood swings, breast tenderness, cramping, and heavy bleeding.  There were also initial concerns that progestin-only bcp’s would increase the risk of breast cancer, in the same way that postmenopausal women taking progestin-only hormone-replacement therapy were found to have an increased risk of breast cancer. However, no statistically significant association has been found to support this hypothesis. Even so, make sure to talk to your doctor about this issue, as research is on-going and individual usage must be assessed on a case-by-case basis.

Dietary Changes/Nutritional Medicine
The relationship between diet and endometriosis is a subject that has attracted a great deal of interest lately. While there is no consensus among experts, patients have been reporting for years that making certain dietary changes has helped reduced symptoms of endometriosis and other gastrointestinal conditions.

The most common foods nutritionists suggest to avoid for those who have endometriosis include:
– soy or other foods containing phyto-estrogens
– dairy products (lactose reduction)
– gluten-containing products (ie, follow the celiac diet)
– saturated fats
– butter and/or lard
– coffee
– sugary foods
– animal and/or organ meat

However, because nutritional medicine is such a complex field, with many competing theories and few well-designed scientific studies, rather than attempting to distill this infinitely complex topic into simple sound bites, we’ve instead offered a few links below to some websites that provide what appears to be well-researched information about how dietary changes may help reduce symptoms of endometriosis and other gynecological or gastrointestinal conditions:


GnRH Agonists
Sold under the brand names Lupron, Zoladex, Trelstar, Viadur, Vantas, Eligard and Synarel, gonadotropin-releasing hormone agonist (GnRH) is a synthetic peptide designed to mimic the hypothalamic hormone GnRH. The GnRH agonist binds to the gonadotropin-releasing hormone receptor, which in turn catalyzes a cascade of biochemical reactions, including the release of the pituitary hormones, follicle-stimulating hormone (FSH), and luteinizing hormone (LH). In turn, it suppresses the release of natural estrogen and progesterone production. GnRH agonists are prescribed for a few different conditions, including endometriosis, and, paradoxically, as part of IVF therapy for brief periods. It’s also prescribed for preoperative improvement of anemia from heavy bleeding caused by uterine fibroids.
Benefits: As a therapy for both endometriosis and fibroids, it can reduce pain, shrink current lesions or fibroids, and reduce the growth of new endometriotic growths. Many surgeons recommend taking GnRH agonists for a brief period of time before surgery because of its ability to significantly reduce the size and bio-activity of endometriotic lesions and/or fibroids. This in turn reduces the inflammation, bleeding, and severe tissue fragility associated with these conditions, all of which help the surgeon more easily visualize, isolate, and then excise the lesions or remove the fibroids without causing damage to the surrounding healthy tissue. It also reduces anemia caused by fibroid-associated heavy bleeding. Used in this way, for a very brief period of time as a pre-surgery adjuvant, patients experience significantly fewer side effects. However, GnRH agonists are not a long-term management option.
Risks: In the endometriosis community, long-term use of the GnRH agonist Lupron in particular is a notoriously controversial subject. This is because, for many women, the side effects of Lupron are simply too numerous and too intolerable, even despite the relief of pain symptoms. For example, inducing temporary menopause in women while they’re still in their 20s-40s is hardly a welcomed event. Bone loss, hot flashes, weight gain, acne, and mood swings are just a few of the most notoriously dreaded side effects. However, other potentially more serious side effects include bone loss severe enough to cause osteoporosis, increased risk of some cancers and pituitary disorders. While these very serious potential side effects are very rare, nevertheless many patients who take GnRHs for longer periods of time (6 months, for example) eventually do discontinue usage due to the inability to tolerate its other side effects. Because of the side effects, GnRH agonists are generally prescribed for periods of no longer than 6 months and are considered only a short-term therapy.

Before receiving GnRH agonists, tell your doctor if you have diabetes, heart disease, a previous heart attack or stroke, or any cardiovascular risk factors like high blood pressure, high cholesterol, or cigarette smoking.

Post-script: New generation GnRH agonists besides Lupron are now available or being developed, which do not cause as many side effects. Therefore, do make sure to ask your doctor about these newer and better tolerated alternatives.

Traditional Chinese Medicine
Another popular trend on the rise for women with endometriosis or other gynecological conditions is the use of herbal supplements and/or Traditional Chinese Medicine (TCM) in conjunction with traditional Western medicine. As with the issue of nutritional medicine, this complex topic is beyond the scope of our website. However, one important caveat we must mention is that many herbal supplements can actually cause harmful side effects during surgery, such as excessive bleeding. Therefore, at least 4 weeks prior to surgery with Dr. Nezhat, all herbal supplements and certain other medications must be discontinued. Other herbal supplements have also been known to worsen your endometriosis symptoms.

This is not to suggest that we believe all alternative medicines to be without benefit. To the contrary, in a recent article Drs. Nezhat noted that preeminent endometriosis researchers like Dr. Linda Giudice have indeed found some substances used in traditional Chinese medicine have shown some potential benefits in laboratory studies. As reported in a recent editorial by Dr. Linda Giudice, preliminary studies suggest that several ‘‘Chinese herbal therapies have exhibited antiproliferative, antinociceptive, and prosedative properties, as well as anti-inflammatory actions, antioxidant characteristics, suppression of COX-2 and cytokines, and mechanisms involved in the cytokine response, such as inhibition of NF-KB’.’ (Click here to read entire article).

Despite this encouraging preliminary research, as a center specializing in surgery, we generally cannot recommend most alternative herbal therapies because of the potentially harmful effects, like excessive bleeding, that some of them may cause duringsurgery.  And, because herbal supplements are not regulated by the FDA, tremendous variations in the purity and amount of active ingredients have been found. For example, despite what the labels say, harmful impurities or phyto-estrogens, for example, may be present, which can and do worsen endometriosis. If you still wish to explore alternative herbal therapies, we can only suggest that you proceed with caution and be sure to let your doctor know what supplements you are taking, so that he or she can limit the possibility of potential adverse drug interactions or provide updates about the latest research on alternative therapies being conducted by Dr. Giudice and other endometriosis specialists.

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