Birth Control Pills for Endometriosis

Main article: Treatment of Endometriosis

For women with endometriosis, hormonal treatment such as birth control pills is the first-line treatment option usually recommended by doctors.¹ Especially because the other treatment option, i.e. surgery, carries inherent risks including postoperative complications (e.g. infection and voiding dysfunction).²

However, birth control pills come in numerous formulations and types which can make choosing one a daunting process.

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
• Ethinyl estradiol/Dienogest

Progestogen-only pill formulations include:

• Dienogest
• Desorgestrel
• Drospirenone

Not to mention a lack of comparative studies between formulations among women with endometriosis and evidence to common questions hidden in unrelated studies.

Lets try to answer some of these questions!

Does Birth Control Cause Endometriosis

Taking birth control will not cause endometriosis.³ In fact, most experts agree that endometriosis is a congenital disorder which already exists at birth in some form or another.⁴

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, retrospective studies show this was only likely in past users of COCPs when estrogen doses were much higher.⁵

Can Birth Control Make Endometriosis Worse

Birth control pills which contain estrogen can sometimes promote the growth of endometriosis and worsen symptoms.

This is most likely to occur in women who are progesterone resistant and or have increased estrogen levels above baseline after beginning birth control.

Does Birth Control Stop the Growth of Endometriosis

Birth control inhibits the growth of endometriosis for two-thirds of women. In the other one-third of women, birth control is not effective. Unfortunately this means for some women endometriosis will continue to grow while on birth control.

Can Birth Control Help Endometriosis

Birth control is effective in two-thirds of women with endometriosis. Birth control treatment normally takes 2 months (i.e. 2 menstrual cycles) to help relieve endometriosis-related symptoms including pain.⁶

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 birth control pill for endometriosis is the Combined Oral Contraceptive Pill (COCP) containing both estrogen and progesterone derivatives.^7,8

However this recommendation does not apply to women diagnosed with only ovarian endometriosis due to a different biology.^9,10 In these women, several studies report the best contraceptive pill is a progestogen-only pill (POP) such as dienogest.^11,12 Although endometriomas do not grow during treatment with dienogest, significant regression is uncommon and surgery may be required eventually.¹³

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.^14,15,16 Dienogest is also reported to significantly worsen the mood in some women.¹⁷ 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.¹⁸

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.^19,20

Mirena, Liletta, Skyla and Kyleena all offer LNG-IUS (levonorgestrel-releasing intrauterine system) of varied doses and time period.

Endometriosis Breakthrough Bleeding on Pill

Breakthrough bleeding including spotting is common in women with endometriosis on the pill. In fact, at least 1 in 10 women with endometriosis still experience spotting after 5 years of combined oral contraceptive pill (COCP) or progestogen-only pill (POP) continued use.⁴

Can Stopping Birth Control Cause Endometriosis

No, stopping birth control (or the pill) will not cause endometriosis. This is because endometriosis is a congenital disorder which already exists at birth in some form or another.³

Obviously, birth control is quite effective at managing endometriosis related symptoms. Therefore women who stop birth control and begin to experience these symptoms for the first time may believe that stopping birth control caused their endometriosis.

Endometriosis Birth Control Not Working

Birth control is not effective in one-third of women with endometriosis due to progesterone resistance or intolerance.²¹

In the other two-thirds of women, taking birth control for endometriosis, birth control will not stop working if taken continuously as directed.

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 (linked to inflammation)²² this strategy is ineffective requiring surgery or other medication to treat effectively.

Treating Endometriosis Without Birth Control

Alternatives to birth control for the treatment of endometriosis include:

• Analgesics (painkillers)
• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Gonadotropin-releasing hormone (GnRH) agonists ²³
• Aromatase inhibitors
• Laparoscopic surgery

For some women, these medications can manage endometriosis related symptoms well enough that surgery is not necessary.²⁴

A Final Tip From Fertility Science

Summing up, the effect of birth control in woman with endometriosis will vary according to the type and formulation of birth control, severity of the disease, genetics and any comorbidities.

As a result, approximately 1 in 2 women will request a change in birth control, due to persisting pain, breakthrough bleeding, gain in weight, headaches or nausea.²⁵

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 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.

References

1. Becker C M, et al. (2022). ESHRE guideline: endometriosis. https://academic.oup.com/hropen/article/2022/2/hoac009/6537540 ↩︎
2. Leborne P, et al. (2022). Clinical outcomes following surgical management of deep infiltrating endometriosis. https://www.nature.com/articles/s41598-022-25751-9 ↩︎
3. Vercellini P, et al. (2010). Oral contraceptives and risk of endometriosis: a systematic review and meta-analysis. https://academic.oup.com/humupd/article/17/2/159/692036 ↩︎
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10. Biyik I, et al. (2021). The deep infiltrating endometriosis tissue has lower T-cadherin, E-cadherin, progesterone receptor and oestrogen receptor than endometrioma tissue. https://www.sciencedirect.com/science/article/pii/S102845592100257 ↩︎
11. Angioni S, et al. (2019). Is dienogest the best medical treatment for ovarian endometriomas? Results of a multicentric case control study. https://www.tandfonline.com/doi/full/10.1080/09513590.2019.1640674 ↩︎
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14. de Bastos M, et al. (2014). Combined oral contraceptives: venous thrombosis. https://doi.org/10.1002/14651858.CD010813.pub2 ↩︎
15. Therapeutic Goods Administration, (2021). Update – Dienogest and risk of venous thromboembolism. https://www.tga.gov.au/news/safety-updates/update-dienogest-and-risk-venous-thromboembolism ↩︎
16. Ebert A D, et al. (2017). Dienogest 2 mg Daily in the Treatment of Adolescents with Clinically Suspected Endometriosis: The VISanne Study to Assess Safety in ADOlescents. https://www.jpagonline.org/article/S1083-3188(17)30036-0/fulltext ↩︎
17. Dietrich H, et al. (2023). Endometriosis features and dienogest tolerability in women with depression: a case-control study. https://www.tandfonline.com/doi/full/10.1080/13625187.2023.2199899 ↩︎
18. Morelli M, et al. (2013). Postoperative administration of dienogest plus estradiol valerate versus levonorgestrel-releasing intrauterine device for prevention of pain relapse and disease recurrence in endometriosis patients. https://obgyn.onlinelibrary.wiley.com/doi/10.1111/jog.12030 ↩︎
19. Kim H, et al. (2022). Long-term efficacy and safety of levonorgestrel-releasing intrauterine system as a maintenance treatment for endometriosis. https://journals.lww.com/md-journal/fulltext/2022/03110/long_term_efficacy_and_safety_of.28.aspx ↩︎
20. Lee K H, et al. (2018). Comparison of the efficacy of diegnogest and levonorgestrel-releasing intrauterine system after laparoscopic surgery for endometriosis. https://obgyn.onlinelibrary.wiley.com/doi/10.1111/jog.13703 ↩︎
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22. Wang Y, et al. (2023). Distinct subtypes of endometriosis identified based on stromal-immune microenvironment and gene expression: implications for hormone therapy. https://www.frontiersin.org/journals/immunology/articles/10.3389/fimmu.2023.1133672/full ↩︎
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