The review looks at three hormone treatments for painful endometriosis—GnRH analogues (like gonadorelin), dienogest, and gestrinone. All work, but each has its own side‑effects: GnRH drugs drop estrogen and can hurt bone health unless you add back some hormones; dienogest keeps bone density but can cause irregular bleeding and mood changes; gestrinone is strong and easy on heart and bones but has androgenic effects that many find off‑putting. Choosing the right one depends on what side‑effects you can tolerate.

<b>Background</b>: The management of endometriosis-associated pain has traditionally focused on analgesic efficacy. However, with high-level evidence demonstrating therapeutic equivalence among principal hormonal classes, the paradigm has shifted towards a patient-centred approach prioritising long-term tolerability and shared decision-making. Objectives: This review critically synthesises the evidence for the three main hormonal therapies-gonadotropin-releasing hormone (GnRH) analogues, dienogest, and gestrinone-focusing on their distinct tolerability and safety profiles to inform this modern clinical framework. <b>Methods</b>: This narrative review followed the SANRA (Scale for the Assessment of Narrative Review Articles) guidelines. The literature search was performed in PubMed, Embase, and Web of Science in June 2025. <b>Results</b>: Our comparative analysis, based on a structured literature search adhering to SANRA guidelines, shows that while all three classes are effective, they present distinct benefit-risk profiles: GnRH analogues offer potent pain relief but induce a hypoestrogenic state requiring add-back therapy to mitigate bone loss and vasomotor symptoms; dienogest preserves bone mineral density but is associated with challenging bleeding patterns and potential mood disturbances; gestrinone provides robust efficacy with a favourable cardiovascular and skeletal safety profile, although its androgenic effects can significantly impact patient adherence. <b>Conclusions</b>: In the absence of a clear hierarchy of efficacy, the optimal therapeutic choice is not determined by potency, but by a collaborative process in which patient values and tolerance for specific adverse effects guide selection. This review provides a framework to facilitate this shared decision-making (SDM) in clinical practice.