Is suppressing the ovulatory cycle enough?

According to American Congress of Obstetricians and Gynecologists (ACOG) guidelines:

Persistent symptoms are one reason to move on from initial treatment options, after first-line failure.1

Stopping the menses to reduce dysmenorrhea may not be enough to comprehensively address endometriosis pain.

Once inadequate pain relief on combined oral contraceptives or progestin-only contraceptives is identified, reasess your management plan.2,3

ACOG Treatment Algorithm for Endometriosis Pain. ACOG Treatment Algorithm for Endometriosis Pain.
*based on recommendations from ASRM and ACOG

ASK specific questions at every office visit to identify unresolved pain5,6

  • How has your pain changed since your last visit?
  • Has your pain lessened, or have you just grown accustomed to it?

View therapies for treating this estrogen-dependent disease1,4,7-10:

  • Inhibit the COX pathway
  • Reduce prostaglandin production
  • Decrease inflammation and primary dysmenorrhea
  • Combined OCs include both a synthetic progestin and estrogen
  • Progestin component helps prevent a rise in estradiol, but synthetic estrogen may result in continued proliferation of endometriosis
  • Continuous combined OCs can prevent estrogen fluctuation
  • Results in decreased secretion of estradiol and increases androgens
  • Decreases estradiol production and improves symptoms
  • Inhibit the production of LH and FSH, necessary triggers for stimulating the ovaries to produce estrogen
  • Suppress estrogen
  • Induce a hypoestrogenic state and improve symptoms
  • Unlike healthy endometrium, endometriotic tissue expresses a high level of aromatase activity that may increase estrogen levels and promote the growth of endometriosis lesions
  • Because they increase FSH levels and promote follicular development, aromatase inhibitors must be used with additional agents, such as GnRH agonists or combined oral contraceptives, in premenopausal women
  • Several small studies have shown aromatase inhibitors to be effective for the treatment of endometriosis and pelvic pain
  • Histologic confirmation of disease
  • Can effectively relieve painful symptoms
  • Symptoms may recur after surgery
  • Disease may be difficult to visualize and/or be present outside of the surgical window

Help your patients
with an action plan designed
for them.
Help your patients  with an action plan designed for them.



  1. American College of Obstetricians and Gynecologists. Practice bulletin no. 114: management of endometriosis. Obstet Gynecol. 2010;116(1):223-236.
  2. Vercellini P, Trespidi L, Colombo A, Vendola N, Marchini M, Crosignani PG. A gonadotropin-releasing hormone agonist versus a low-dose oral contraceptive for pelvic pain associated with endometriosis. Fertil Steril. 1993;60(1):75-79.
  3. Harada T, Momoeda M, Taketani Y, Hoshiai H, Terakawa N. Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis: a placebo-controlled, double-blind, randomized trial. Fertil Steril. 2008;90(5):1583-1588.
  4. Practice Committee of American Society for Reproductive Medicine. Treatment of pelvic pain associated with endometriosis: a committee opinion. Fertil Steril. 2014;101(4):927-935.
  5. Yeh J, Nagel EE. Patient satisfaction in obstetrics and gynecology: individualized patient-centered communication. Clin Med Insights Womens Health. 2010;3:23-32.
  6. Vercellini P. Introduction: management of endometriosis: moving toward a problem-oriented and patient-centered approach. Fertil Steril. 2015;104(4):761-763.
  7. Kodaman PH. Current strategies for endometriosis management. Obstet Gynecol Clin North Am. 2015;42(1):87-101.
  8. Danocrine [package insert]. Bridgewater, NJ: Sanofi-Aventis. US LLC; 2011.
  9. Lupron Depot [package insert]. North Chicago, IL: AbbVie Inc; 2016.
  10. Giudice LC. Clinical practice: endometriosis. N Engl J Med. 2010;362(25):2389-2398.