Endometriosis (cont.)
How is endometriosis treated?
Endometriosis can be treated with medications and/or surgery. The goals of
endometriosis treatment may include pain relief and/or enhancement of fertility.
Medical treatment of endometriosis
Nonsteroidal anti-inflammatory drugs or NSAIDs (such as ibuprofen or naproxen sodium) are commonly prescribed to help
relieve pelvic pain and menstrual cramping. These pain-relieving medications
have no effect on the endometrial implants. However, they do decrease
prostaglandin
production, and prostaglandins are well-known to have a role in production of
pain sensation. Because the diagnosis of endometriosis is only definite after a
woman undergoes surgery, there will of course be many women who are suspected of
having endometriosis based on the nature of their pelvic pain
symptoms. In such a situation, NSAIDs are commonly used. If they work to control
pain, no other procedures or medical treatments are needed. If they do not
relieve the pain, additional evaluation and treatment generally occur.
Since endometriosis occurs during the reproductive years,
many of the available medical treatments for endometriosis rely on interruption
of the normal cyclical hormone production by the ovaries. These medications
include GnRH analogs, oral contraceptive pills, and progestins.
Gonadotropin-releasing hormone analogs (GnRH analogs)
Gonadotropin-releasing hormone analogs (GnRH analogs) have been effectively
used to relieve pain and reduce the size of endometriosis implants. These drugs
suppress estrogen production by the ovaries by inhibiting the secretion of
regulatory hormones from the pituitary gland. As a
result, menstrual periods stop, mimicking menopause. Nasal and injection forms of GnRH agonists are
available.
The side effects are a result of the lack of estrogen, and include:
Fortunately, by adding back small
amounts of estrogen and progesterone in pill form
(similar to treatments sometimes used for symptom relief in
menopause) many of the annoying side effects due to estrogen deficiency can be
avoided. "Add back therapy" is the term that refers to this modern way of
administering GnRH agonists along with estrogen and progesterone in a way to
keep the treatment successful, but avoid most of the unwanted side effects.
Oral contraceptive pills
Oral contraceptive pills (estrogen and progesterone in
combination) are also sometimes used to treat endometriosis. The most common
combination used is in the form of the oral contraceptive pill (OCP). Sometimes women who have severe
menstrual pain are asked to take the OCP continuously, meaning skipping the
placebo (sugar pill)
portion of the cycle. Continuous use in this manner will free a woman of having
any menstrual periods at all. Occasionally, weight gain,
breast tenderness,
nausea, and irregular bleeding are mild side effects.
Oral contraceptive pills
are usually well-tolerated in women with endometriosis.
Progestins
Progestins [for example,
medroxyprogesterone
acetate (Provera, Cycrin, Amen), norethindrone acetate,
norgestrel acetate (Ovrette)] are more potent than birth
control pills and are
recommended for women who do not obtain pain relief from or cannot take a birth
control pill.
Side effects are more common and include:
Since the
absence of menstruation (amenorrhea) induced by
high doses of progestins can last many months after cessation of therapy, these
drugs are not recommended for women planning pregnancy.
Other drugs used to treat endometriosis
Danazol (Danocrine)
Danazol (Danocrine) is a synthetic drug that creates a high androgen (male type
hormone) and low estrogen hormonal environment by interfering with ovulation and
ovarian production of estrogen. Eighty percent of women who take this drug will
have pain relief and shrinkage of endometriosis implants, but up to 75% of women
develop side effects from the drug.
Side effects can include:
- weight gain,
- edema,
- decreased breast size,
- acne,
- oily skin,
- hirsutism (male pattern hair growth),
- deepening of the voice,
- headache,
- hot flashes,
- changes in libido, and
- mood
changes.
All of these changes are reversible, except for voice changes; but the
return to normal may take many months. Danazol should not be taken by women with
certain types of liver, kidney, and heart conditions.
Aromatase inhibitors
A newer approach to the treatment of endometriosis has involved the
administration of drugs known as aromatase inhibitors [for example,
anastrozole (Arimidex) and
letrozole (Femara)]. These drugs act by interrupting local estrogen
formation within the endometriosis implants themselves. They also inhibit
estrogen production in the ovary, brain, and other sources, such as adipose
tissue. Research is still ongoing to characterize the effectiveness of aromatase
inhibitors in the management of endometriosis. Aromatase inhibitors cause
significant bone loss
with prolonged use and cannot be used alone without other medications in
premenopausal women because they stimulate development of multiple follicles at
ovulation.
Next: Surgical treatment of endometriosis »
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