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Main article: Treatment of Endometriosis
For women with endometriosis, hormonal treatment such as birth control pills is a first-line treatment option most commonly recommended by doctors. This is because the other treatment option, i.e. surgery, carries inherent risks such as infection and voiding dysfunction.
Nowadays there are numerous formulations and types of birth control pills to choose from.
The 2 main types of birth control pills are:
- Combined oral contraceptive pill (COCP).
- Progestogen-only pill or progestin-only pill (POP), also known as the minipill.
Common COCP formulations include: ethinyl estradiol/levonorgestrel, ethinyl estradiol/desogestrel, ethinyl estradiol/dydrogesterone, ethinyl estradiol/drospirenone, estradiol valerate/dienogest and ethinyl estradiol/dienogest.
Progestogen-only pill formulations include: dienogest, desorgestrel and drospirenone.
With so many choices it’s easy to get lost.
It is even more challenging for women with endometriosis with a lack of comparative studies and evidence to common questions hidden in unrelated studies.
Lets try to answer some of these questions!
Does Birth Control Cause Endometriosis
No, birth control does not cause endometriosis. In fact, most experts agree that endometriosis is a congenital disorder which already exists at birth in some form or another.
In saying that, endometriosis is also an estrogen-dependent disease which can be influenced by birth control depending on the formulation. Combined oral contraceptives which include estrogen can in theory promote the growth of endometriosis lesions. However, in reality studies show this may only be true for past users of COCPs when estrogen doses were much higher.
Can Birth Control Make Endometriosis Worse
Yes, birth control pills which contain estrogen can in fact promote the growth of endometriosis and worsen symptoms since endometriosis is an estrogen-dependent disease.
This is most likely to occur in women who are progesterone resistant and or have increased estrogen levels above normal after beginning birth control. In short, endometriosis can still grow while on birth control for some women.
Can Birth Control Help Endometriosis
Birth control is helpful in two-thirds of women with endometriosis. It generally takes 2 months (i.e. 2 menstrual cycles) for birth control to help manage endometriosis and its symptoms.
On the other hand, women who experience minimal or no change in endometriosis related symptoms after 3 months of birth control should speak to their doctor and discuss other treatment options.
Best Contraceptive Pill for Endometriosis
The best contraceptive pill for endometriosis is the Combined Oral Contraceptive Pill (COCP) containing both estrogen and progesterone derivatives.
This is because of evidence which suggests the addition of ethinyl estradiol (derivative of estradiol) to progestin only pills (such as desogestrel) increases the death of endometriosis cells. An earlier laboratory study reported this effect was dependent on cells that expressed estrogen receptor alpha (which activated progesterone receptor B).
Recent studies suggest the fourth-generation progestin named dienogest is highly effective at stopping the progress of endometriosis on its own and maybe somewhat better when combined with an estrogen derivative (i.e. estradiol valerate and ethinyl estradiol). Of these 2 potential combinations there is some evidence to suggest dienogest and ethinyl estradiol combined lowers estrogen levels significantly more than dienogest/estradiol valerate. This is worth considering given endometriosis is an estrogen-dependent disease.
However, for women diagnosed only with ovarian endometriosis, the best contraceptive pill is a progestogen-only pill (POP) such as dienogest. Although endometriomas do not grow during treatment with dienogest, significant regression is uncommon and surgery may be likely.
Please note, like any medication there is potential side effects associated with oral contraceptive pills. This includes venous or arterial thrombosis (up to 11 cases per 10,000 women a year) and decreased bone mineral density depending on the formulation. Please ask your doctor about these risks and how relevant they are to you.
Birth Control Pill vs IUD for Endometriosis
The birth control pill is effective against all forms of endometriosis, but an intrauterine device (IUD) such as LNG-IUS is generally better for ovarian endometriosis post-surgery.
This is because of its location and the set and forget nature of an IUD with studies reporting similar efficacy to birth control pills post-surgery but less side effects long term.
Endometriosis Breakthrough Bleeding on Pill
Breakthrough bleeding including spotting is common in women with endometriosis on the pill. In fact, approximately 1 in 5 women with endometriosis still experience spotting after 5 years of combined oral contraceptive pill (COCP) or progestogen-only pill (POP) continued use.
Can Stopping Birth Control Cause Endometriosis
No, stopping birth control (or the pill) does not cause endometriosis. This is because endometriosis is a congenital disorder which already exists at birth in some form or another.
However, birth control is reasonably effective at managing endometriosis related symptoms. Therefore, women who stop birth control and begin to experience endometriosis related symptoms for the first time may inevitably think that stopping birth control caused endometriosis.
Endometriosis Birth Control Not Working
In one-third of women with endometriosis, birth control does not work effectively due to progesterone resistance or intolerance.
In cases of intolerance, women with endometriosis are generally switched to a different birth control formulation or type. However, for women diagnosed with progesterone resistance this strategy is ineffective. This leaves surgery or other hormonal medication as the remaining treatment options for your doctor to recommend.
Treating Endometriosis Without Birth Control
Endometriosis is commonly treated without birth control by laparoscopic surgery. However, surgery is not the only other option for women diagnosed with endometriosis. Analgesics (painkillers), non-steroidal anti-inflammatory drugs (NSAIDs), gonadotropin-releasing hormone (GnRH) treatments and aromatase inhibitors can also manage endometriosis related symptoms well enough for some women that surgery is not required.
A Tip From Fertility Science
The effect of birth control in woman with endometriosis will vary somewhat depending on the type and formulation of birth control, severity of the disease, genetics and any comorbidities.
To quantify this better, your doctor may ask you to keep a daily diary of any symptoms and the level of discomfort using a visual analog scale (VAS).
This allows both you and your doctor to evaluate the efficacy of the recommended treatment with some degree of accuracy and also compare it to other treatments in the future if need be.
Fortunately, research on alternative treatment options for endometriosis is growing exponentially, that using birth control to treat endometriosis may become a thing of the past very soon.
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