ESHRE Logo ESHRE Guideline for the Diagnosis and Treatment of Endometriosis

Coping with disease
(supporting documentation)

Complementary therapies

There is evidence from two systematic reviews suggesting that high frequency TENS, acupuncture, vitamin B1 and magnesium may help to relieve dysmenorrhoea (Proctor et al., 2002; Proctor and Murphy, 2001). One RCT has shown that vitamin E may relieve primary dysmenorrhoea and reduce blood loss (Ziaei et al., 2005). Whether such treatments are effective in endometriosis associated dysmenorrhoea and heavy bleeding is unknown.
Level 4

Many women with endometriosis report that nutritional and complementary therapies such as homeopathy, reflexology, Traditional Chinese Medicine, herbal treatments, etc, do improve pain symptoms. Whilst there is no evidence from RCTs in endometriosis to support these treatments, they should not be ruled out if the woman feels that they could be beneficial to her overall pain management and/or quality of life, or work in conjunction with more traditional therapies.

Many consumers are now seeking complementary therapies over conventional medicine. In the field of menstrual disorders, there is some support for this approach from a systematic review suggesting that nutritional intake and metabolism may play an important role in the cause and treatment of such problems (Proctor and Murphy, 2001).

In three double-blinded, but small, RCTs it was shown that magnesium was more effective than placebo for pain relief and the need for additional medication was less (Davis, 1988; Fontana-Klaiber and Hogg, 1990; Seifert et al., 1989). The largest of these trials (n=50) also reported that women taking the magnesium therapy had substantially lower levels of PGF2-al in their menstrual blood than those on placebo (p<0.05), which mirrored the therapeutic decrease in pain experienced by the participants (Seifert et al., 1989). Overproduction of PGF2 has been shown to be a substantial contributing factor to the painful cramps associated with dysmenorrhoea. This emphasises the potential biological rationale behind magnesium therapy for dysmenorrhoea, as magnesium inhibits the biosynthesis of PGF2-a as well as having a role in muscle relaxation and vasodilation (Altura and Altura, 1985; Reavely, 1998).

Vitamin B1 plays an important role in metabolism and deficiency can result in fatigue, muscle cramps, various pains, and a reduced tolerance to pain, which are all factors that can be associated with dysmenorrhoea (Reavely, 1998). This may be why one large trial (n=556) showed a daily intake of 100mg of vitamin B1 for two months to be an effective treatment for dysmenorrhoea, with none of the women taking placebo experiencing complete pain relief (Gokhale, 1996).

In a randomised controlled trial 278 girls aged 15-17 with primary dysmenorrhoea were given 200 units of vitamin E or placebo twice a day, beginning two days before the expected start of menstruation and continued through the first three days of bleeding over four consecutive menstrual periods. At four months, the vitamin E group had lower pain severity assessed by visual analogue scale (0.5 vs. 6, p>0.001), shorter pain duration (1.6 hours vs. 17 hours, p>0.0001) and reduced blood loss assessed by pictorial blood loss assessment chart (46 vs. 70, p>0.0001). (Ziaei et al., 2001).

Another systematic review concluded that transcutaneous electrical nerve stimulation (TENS) and acupuncture can be effective in the treatment of dysmenorrhoea. Though there was insufficient evidence to determine and assess the treatments accurately, the reviewers concluded that TENS represents a suitable alternative for women, who prefer not to use medication or wish to minimise their intake of NSAIDs (Proctor et al., 2002).

Whether any of these treatments are effective in endometriosis associated dysmenorrhoea has not been shown.

Proctor et al highlight that one small but methodologically sound trial of acupuncture suggests benefits for this modality (Helms, 1987), and in a retrospective study of 47 families with paediatric pain patients (median age 16, 6 of whom were diagnosed with endometriosis) 70% felt the treatment helped their symptoms (Kemper et al., 2000).

A randomised controlled trial of 90 women with endometriosis compared Shu-Mu acupuncture (n=30), routine needling acupuncture (n=30) and oral Danazol (n=30). The total effective rate was similar in the three groups, however the Shu-Mu point combination group was superior to the other two groups in improvement of dysmenorrhoea and irregular menstruation, and serum CA125 in the Shu-Mu point combination treated group was significantly decreased (Sun and Chen, 2006).

Extending the therapeutic network

Given the chronic and stubborn nature of endometriosis, there may be times when it can be beneficial to extend the therapeutic network beyond the medical mainstream; especially when women report that nutritional and complementary therapies, such as homeopathy, reflexology, Traditional Chinese Medicine (TCM), herbal treatments, physiotherapy, etc, improve their pain symptoms.

Whilst there is no evidence from any of the above to support these treatments in endometriosis related symptoms these should not be ruled out if the woman feels that they are beneficial to her overall pain management and/or quality of life.

Nutritional therapy/dietry modification

Nutritional therapy/dietry modification has shown promising effects on dysmenorrhoea in three small RCTs, specifically supplementation with omega-3 fish oil combined with vitamin B12 and a diet high in vegetables and low in animal fats (Harel et al., 1996; Deutch et al., 2000; Barnard et al., 2000). Parazzini et al found that intake of fruit and green vegetables decreased the risk of endometriosis, whereas ham, beef and other red meat increased the risk (Parazzini et al., 2004), Several studies also link fibre intake to an increased oestrogen excretion (Rose et al., 1997; Kaneda et al., 1997).

An RCT of 80 women with endometriosis demonstrated that two months of high-dose vitamin E and C therapy was associated with significant improvement in endometriosis pain and a reduction in inflammatory markers (Santanam et al., 2003). Another two randomized, double-blinded, placebo controlled trials have demonstrated significant decrease in median pain scores in the groups treated with vitamin E compared to placebo for primary dysmenorrhoea (Butler et al., 1955; Ziaei et al., 2001; Ziaei et al., 2005).


In a very small, non-randomised, study in eight patients diagnosed with endometriosis, five out of seven, who had dysmenorrhoea, reported relief from symptoms (and two had intermittent relief) following individualised homeopathic treatment (Hunton, 1993).

Herbal remedies/Traditional Chinese Medicine

A systematic review (Proctor and Murphy, 2001) concluded that there was insufficient evidence to recommend the use of the herbal remedies considered in the review. One small trial, however, showed that a herbal combination was more effective for pain relief than placebo and that less rescue medication was needed by the treatment group (Kotani et al., 1997).

A randomised controlled trial, which compared Yiweining (YWN) with Gestrinone post-operatively showed a recurrence rate of 5.0% and 5.3% respectively compared with a 30.7% in the placebo group, however, the adverse reaction rate in the YWN was lower (10.0%) than that in the Gestrinone group (31.6%) (Yang et al., 2006).

Furthermore, Qu et al have demonstrated in endometriosis model rats that the Chinese herb Yiweining (YWN) can prevent the growth of ectopic endometrium by inhibiting the synthesis and secretion of TNF-alpha, IL-6, and IL-8 (Qu et al., 2005), and can reduce the positive expressions of MMP-2 and COX-2 mRNAs (Qu et al., 2006).


Whereas physiotherapy, yoga, Pilates, and gentle exercise may assist the body in getting back into shape during/after prolonged periods of pain and/or after surgery to strengthen compromised pelvic/abdominal/back muscles, and whereas reflexology has anecdotally been reported to relieve pain symptoms, there is no evidence published relating to their therapeutic effect on dysmenorrhoea or endometriosis-related symptoms.

Patient support groups

GPP Patient self-help groups can provide invaluable counselling, support and advice. The website provides a comprehensive list of all the self-help groups in the world. Self-management programmes may prove beneficial in providing the woman with tools to enable her to live with a chronic disease.

Patient support groups and self management

Physical and psychological trauma can contribute to a negative self-image and negative internal dialogue (Stones, 2000). Thus some women with endometriosis may benefit from working with a counsellor/psychologist, in particular a pain psychologist, to develop strategies on how to cope with endometriosis including breaking the pain cycle, dealing with stress and anxiety, and resolve feelings about infertility.

Self-management (also called the Expert Patients Programme) is a rigorously researched patient led programme developed by Stanford University in the United States. Coventry University has researched self-management in the United Kingdom and their findings support the Stanford research.

The underlying basis of the course is the symptom/pain cycle, showing the interaction between disease, fatigue, depression, anger/fear/frustration, stress/anxiety and tense muscles. The aim of the course is to provide tools to break the cycle at any given point through weekly sessions with tutors, who also have chronic diseases (see: for more information).

For some women, all they need is to talk to others with the disease - to share mutual experiences, coping techniques, and discuss treatment methods. Patient organisations play an important role in providing women and girls with emotional support, and collaborate closely with physicians and legislators in providing guidance and information about the disease. A list of current global resources for support can be found at:







This guideline, which is reviewed annually, was last updated on 30 June 2007

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