Secondline agents consist of one of the following

1. Continuous progestin treatment. Medroxyprogesterone acetate (50 mg orally daily), norethindrone acetate (eg, Aygestin 5 mg orally daily), norgestrel (eg, Ovrette 0.075 mg orally daily), or norethindrone (eg, Micronor, Nor-QD 0.35 mg orally daily) for a two-month trial.

2. Danazol 200 to 400 mg/day in two divided doses initially, may be increased to 800 mg/day in two divided doses to achieve amen-orrhea. Therapy may be continued up to nine months.

3. Empiric use of a gonadotropin-releasing hormone (GnRH) agonist analogue (eg, leuprolide [3.75 mg intramuscularly every four weeks] or nafarelin [200 pg intranasally twice daily]) for 2 months. An add-back regimen should be considered.

4. Surgical intervention, such as laparoscopy or cystoscopy, can be considered if medical interventions are not successful or as an initial procedure to exclude neoplasia or an endometrioma.

C. Low probability of endometriosis. Women in whom a particular disease process is suspected, such as adenomyosis, uterine leiomyomata, irritable bowel syndrome, interstitial cystitis, diverticulitis, or fibromyalgia should undergo further diagnostic testing and disease-specific treatment.

1. Women with suspected pelvic inflammatory disease infection can be treated with doxycycline 100 mg orally twice daily for 14 days.

2. NSAIDs can be prescribed at doses in the upper end of the dose range (eg, ibuprofen 800 mg orally every six hours).

3. Antidepressants, opioids, anticonvulsants, and psychotherapy are used for treatment of chronic pain.

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