Medical treatment of endometriosis-related pain

Available medical treatments for symptomatic endometriosis act by inhibiting ovulation, reducing serum oestradiol levels, and suppressing uterine blood flows. To this aim, several drugs can be used, with a similar magnitude of effect, in term of pain relief, independently of the mechanism of action. Conversely, safety, tolerability, and cost differ. Medications for endometriosis can be categorised into low-cost drugs, including OCs and most progestogens, and high cost drugs, including dienogest and GnRH agonists. As the individual response to different drugs is variable, a stepwise approach is suggested, starting with OCs or low-cost progestogens, and stepping up to high-cost drugs only in case of inefficacy or intolerance. Oral contraceptives may be used in women with dysmenorrhoea as their main complaint, and when only superficial peritoneal implants or ovarian endometriomas < 5 cm are present, while progestogens should be preferred in women with severe deep dyspareunia and when infiltrating lesions are identified.