Endometriosis
Non-hormonal and complementary treatments for endometriosis
What the evidence says about painkillers, physiotherapy, psychological support, diet and supplements
Hormonal treatment is the basis of endometriosis care, but it is not always enough and not always possible. Some women want to become pregnant and cannot take hormones. Others do not tolerate the side effects or have health reasons that rule out certain medicines. And some women still have pain despite hormonal treatment.
Pain in endometriosis does not come only from the endometriosis lesions. Chronic inflammation, sensitization of the nervous system, tension in the pelvic floor muscles and bowel and bladder problems all contribute to it. This is why non-hormonal treatments have a place, mainly as an addition. The 2022 ESHRE guideline stresses, however, that for most of them the evidence is still limited.
Which painkillers help?
Non-steroidal anti-inflammatory drugs, such as ibuprofen and naproxen, reduce the production of prostaglandins, the substances that cause cramps and inflammation. They are the most widely used medicines for period pain, and the guideline accepts that they can be used. The evidence specifically for endometriosis, however, is poor. A 2017 Cochrane review found only one small trial of 24 women and could not conclude whether these medicines work in endometriosis.
Anti-inflammatory painkillers work best when taken early, before the pain becomes severe. They can upset the stomach and, with long-term use, cause stomach ulcers or kidney damage. Paracetamol is a gentler option. Opioids are not suitable for long-term use in endometriosis, because they cause dependence and constipation and, over time, can increase sensitivity to pain.
Do medicines for nerve pain help?
When pain becomes chronic, it can take on features of neuropathic pain. For this reason, medicines such as gabapentin, amitriptyline and duloxetine are often used. The guideline cannot recommend them for endometriosis, because there are not enough data.
The largest study on the subject, GaPP2 (The Lancet, 2020), included 306 women with chronic pelvic pain and no visible cause at laparoscopy. Gabapentin for 16 weeks did not reduce pain more than placebo and caused more side effects, such as dizziness, drowsiness and visual disturbances. The study was not specifically about endometriosis, but it shows that these medicines should not be given as an obvious solution.
What the evidence shows
How can pelvic floor physiotherapy help?
Chronic pain often leads to constant tension in the pelvic floor muscles. This tension causes pain during sex, pain when passing urine or opening the bowels and a feeling of pressure in the pelvis, even when the endometriosis lesions are controlled by treatment. Specialized pelvic floor physiotherapy, with relaxation techniques, manual therapy and biofeedback, can reduce these symptoms. A 2025 meta-analysis showed that physiotherapy techniques reduce endometriosis pain, especially when applied locally. The studies are small, but the risk is minimal.
Do exercise, heat and nerve stimulation help?
Regular exercise reduces chronic pain in general, improves mood and sleep and reduces fatigue. For endometriosis specifically, a 2025 meta-analysis of six randomized trials with 251 women showed that exercise, yoga and relaxation techniques reduce pain and improve quality of life. The studies, however, are small and the evidence is weak. Heat on the abdomen, for example with a hot-water bottle, relieves period pain. Transcutaneous electrical nerve stimulation (TENS) uses a simple device and can help some women, although the evidence is limited.
Why does psychological support matter?
Chronic pain changes the way the brain processes pain signals. Anxiety, depression and poor sleep make pain worse, and pain in turn worsens mood and sleep. Cognitive behavioral therapy, mindfulness techniques and pain psychology help to break this cycle. A 2024 meta-analysis of seven randomized trials with 757 women showed that psychological treatments reduce pain during sex and when opening the bowels, as well as anxiety and depression. Pelvic pain decreased less. These treatments do not “cure” endometriosis, but they reduce the impact of pain on a woman's life. More in the article “Endometriosis”.
Can diet make a difference?
No diet has been shown to cure endometriosis. A 2022 systematic review found, however, that the Mediterranean diet reduced pain in one randomized trial. Many women with endometriosis also have bowel symptoms, such as bloating, abdominal pain and irregular bowel habits. In these women, a low-FODMAP diet, which is low in certain carbohydrates that ferment easily in the gut, may help. In a 2017 retrospective study, 72% of women with endometriosis and irritable bowel syndrome had more than a 50% improvement in bowel symptoms after four weeks. The data, however, come from small retrospective studies, not from randomized trials.
Strict diets without guidance, such as cutting out whole food groups, can lead to deficiencies and strain a woman's relationship with food. The low-FODMAP diet is meant for a limited time, ideally with the help of a dietitian, and is followed by a gradual reintroduction of foods.
Do supplements help?
Many supplements are promoted for endometriosis, but few have been studied in women. Melatonin is an example of how uncertain the evidence is. In a 2013 randomized trial of 40 women, melatonin 10 mg for 8 weeks reduced daily pain by about 40%, reduced the use of painkillers by 80% and improved sleep. A second randomized trial from 2023, also with 40 women and a dose of 20 mg, showed no better result than placebo.
Omega-3 fatty acids, vitamin D, curcumin and resveratrol have anti-inflammatory effects in the laboratory. The clinical studies, however, are small and the results conflicting. Supplements are not tested like medicines and can interact with other treatments. For this reason, a woman should tell her doctor about every supplement she takes.
Does cannabis help?
Many women with endometriosis use cannabis for pain and, in questionnaire studies, report relief and lower use of painkillers. A 2025 review, however, found no high-quality randomized trials. The data come mainly from questionnaires. The effectiveness and safety of long-term use are not known, and cannabis can affect concentration, mood and the ability to drive.
Does acupuncture help?
Some small studies show a reduction in pain with acupuncture. Their quality, however, is low, and it is difficult to compare acupuncture with a proper sham treatment. The guideline cannot recommend it. A woman who wants to try it can do so as an addition, not instead of treatment.
What should women be careful about?
Many promises surround endometriosis, such as “detox” diets, expensive products and therapies that promise a cure. None of them has been proven. Any method that delays diagnosis or effective treatment can cause harm, because pain that lasts for years becomes chronic and harder to treat.
The practice's approach
Non-hormonal and complementary treatments do not replace treatment of endometriosis with medication. They can, however, complement it, reduce pain and improve quality of life.
At the practice, every method is looked at critically. A lack of high-quality studies does not always mean that a method does not help, but it does mean that a woman should know what is proven and what is not. The decision is made together with the woman, based on the evidence, the risks and her own preferences.
The aim is a combination of treatments tailored to each woman, so that pain is controlled and her quality of life is protected.
Sources: Becker CM et al., ESHRE guideline: endometriosis, Human Reproduction Open 2022. Brown J et al., Nonsteroidal anti-inflammatory drugs for pain in women with endometriosis, Cochrane Database of Systematic Reviews 2017. Horne AW et al., Gabapentin for chronic pelvic pain in women (GaPP2): a multicentre, randomised, double-blind, placebo-controlled trial, The Lancet 2020. Nirgianakis K et al., Effectiveness of dietary interventions in the treatment of endometriosis: a systematic review, Reproductive Sciences 2022. Schwertner A et al., Efficacy of melatonin in the treatment of endometriosis: a phase II, randomized, double-blind, placebo-controlled trial, Pain 2013. Söderman L et al., Adjuvant use of melatonin for pain management in endometriosis-associated pelvic pain: a randomized double-blinded, placebo-controlled trial, PLoS One 2023. Can G et al., Physiotherapy for endometriosis-associated pelvic pain: a systematic review and meta-analysis, Pain Medicine 2025. Xie M et al., The effectiveness and safety of physical activity and exercise on women with endometriosis: a systematic review and meta-analysis, PLoS One 2025. del Pino-Sedeño T et al., Effectiveness of psychological interventions in endometriosis: a systematic review with meta-analysis, Frontiers in Psychology 2024. Moore JS et al., Endometriosis in patients with irritable bowel syndrome: specific symptomatic and demographic profile, and response to the low FODMAP diet, Australian and New Zealand Journal of Obstetrics and Gynaecology 2017. McLaren K et al., A scoping systematic review of cannabis use in endometriosis, Australian and New Zealand Journal of Obstetrics and Gynaecology 2025.