Hormonal Suppression

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These are medications such as:

• GnRh drugs: these lower estrogen often to menopausal or near menopausal levels
  • Agonists: Lupron, Zoladex, Synarel, Prostap, Decapeptyl, etc
  • Antagonists: Orlissa, Myfembree, Ryeqo, Yselty, etc
• combined hormonal contraceptives
  • this can be a pill, transdermal patches, or vaginal ring
• progestins
  • Visanne/Dienogest, Depo Provera, the Mirena IUD, norethisterone, etc

Hormonal suppression is mainly used for managing endometriosis symptoms

Not everyone sees symptom relief on hormonal medications.  For many patients, hormones can help improve their quality of life, but any symptom relief is usually temporary and typically returns when the person stops the medication.

It’s important to understand the limitations of hormones and what they can’t do. There is no guarantee that taking hormones will prevent progression or disease recurrence, yet many patients are told this. You may be taking hormones under the false impression that you are helping your disease, sticking out intolerable side effects like changes to your libido or mental health, when in reality you’re putting yourself through negative side effects for potentially no disease benefit. This is why informed consent is so important, so you can weigh potential risks vs benefits based on the facts.

If a doctor tells you that hormones do X for endometriosis, the question should be: Where is the proof of this? What studies show this?

“Although the scientific community is trying to find an algorithm of treatment for endometriosis that can be universally applied, to date, there is no ideal drug that can prevent, inhibit, or stop the development of endometriosis. Almost all of the currently available treatment options for endometriosis suppress ovarian function and are not curative.” (1)

It’s important to know that endometriosis can make its own estrogen via the aromatase enzyme, so even when a person goes into a low estrogen state due to hormonal medications, endometriosis can make its own estrogen via aromatase, which is independent of the hormone production of estrogen in the ovaries.

Hormonal suppression doesn’t remove endometriosis lesions

However, due to misinformation, many gynecologists use these various methods as ‘treatment’ for the disease itself. They often wrongly believe that endometriosis will be ‘cleaned up’, ‘dried up,’ or ‘removed’ using one of these treatments, but this is simply not true.

The “studies” on how Lupron or Zoladex shrink endometriosis are flawed. They does not shrink the lesions. I break down a Lupron study here, and Kate from EndoGirlsBlog breaks down Zoladex here.

Hormonal suppression and disease progression

There has been very little studies done on disease progression. We know for a FACT that endometriosis CAN and DOES progress for some patients while they are on hormonal suppression, even those who are on it for a decade or more, even for those who have no symptoms! Unfortunately, some patients are told that hormones will slow or stop the progression of endometriosis. In theory, this could be possible for some patients, but I haven’t seen any solid data on this. A systemic review and meta-analysis came out in 2024 which combined results from 19 students on deep endometriosis and found that there was less progression in patients who were taking hormones than patients who weren’t, but many of the studies used were of low quality or had bias, and among them, they had different definitions of progression. Even if hormonal suppression were to slow or stop progression in some patients, we wouldn’t know in who, so it’s not something as a patient that we should count on.

For some people, hormonal suppression does help them reduce inflammation and help their endometrioma temporarily stop growing and or temporarily reduce in size. But again, this is not the case in ALL patients and if you are thinking of going on hormonal suppression because you have an endometrioma that you hope it will help, it’s recommended that you do continued monitoring and do ultrasounds to see what effect, if any, hormonal suppression is having on your endometrioma.

Hormonal suppression and recurrence

There are 3 types of endometriosis, and each of them are different. Most studies have been done on endometriomas, because they are easy to diagnose and monitor via ultrasound. But conclusions about one type of endometriosis shouldn’t be applied to the other types.

Endometriomas

These can be responsive to ovarian hormones. Multiple studies done on endometriomas suggest that taking hormones post operatively can often help to slow potential endometrioma recurrence for some people. 

Superficial and deeply infiltrating endometriosis

As far as I’m aware, there is no solid proof based on good research that hormonal suppression reduces superficial or deep endometriosis recurrence rates.

Having said that, always make sure you do your own research to find the most up-to-date information. And additionally, don’t just trust that hormones “prevent recurrence” just because your doctor says. Unfortunately, I’ve seen meta-analysis studies that make the conclusion “hormones lower endometriosis recurrence!” but when you look at the studies they included, they were all on endometriomas  and didn’t include any studies on superficial or deep disease.

Symptoms recurrence

In terms of symptoms recurrence post surgery, there are various studies which show that hormonal suppression may help with additional pain relief post excision, or may extend the time a patient is pain free post excision.

Choosing what hormonal suppression to use

You are not obligated to use hormonal suppression if you have endometriosis.

If you choose to use hormonal suppression to try and help your symptoms, remember that it’s truly individual, and there is no one best option for everyone. Since there are multiple kinds, people often need to do trial and error to find one that works for them. There are many options out there, much more than the doctor often presents to us. Often we don’t even get options – the doctor just tells us to take X medication (such as a Dienogest or Orilissa). These might be good options for some people, but there are many more options available as well.

Many people start with oral contraceptive pills. They are relatively cheap and typically accessible for many people. They can often be taken for years and have a lower side effect profile. 

Hormonal suppression can have side effects

Each type of hormonal suppression has potential side effects, with GnRh drugs having a higher side effect profile. GnRh drugs are supposed to be second-line therapies, meaning that they are prescribed when first-line therapies (oral contraceptive pills and progestins) are ineffective, not tolerated or contraindicated. Unfortunately, some doctors put their patients on these right away, as soon as they suspect endometriosis, and for much longer than the FDA approved time frame. You have a right to say no to medications, research them before trying them, or tell the doctor that you want to try other options instead.

People typically need trial and error to see how they tolerate the side effects of different hormonal medications. If one hormone has intolerable side effects, it doesn’t mean they all will. It depends on the type of hormone, the dose, and even the specific progestin used.

How effective is hormonal suppression for symptom management?

Multiple studies have shown that different types of hormones can improve a patient’s quality of life and help reduce pelvic pain.

For example, Buggio et al. did a review on available progestins for endo management, including oral norethisterone acetate, dioenogest, desorgestrel, cyproterone acetate, depot medroxyprogesterone acetate (DMPA), as well as levonorgestrel-releasing intrauterine system (LNG-IUS), etonorgestrel subdermal implant. Those researchers concluded that all available progestins are effective in controlling pain symptoms in two-thirds of people with endometriosis. (2)

“According to the available evidence and to the guidelines issued by major gynecologic societies, there are no major differences in terms of efficacy between various hormonal regimens. As a consequence, the issues of safety, tolerability, and costs are decisive, and in this regard a consensus exists on the indication of estrogen-progestins and progestins as the first-line medical treatment option.” (3)