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 such as ibuprofen or naproxen 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:
- hot flashes,
- vaginal dryness,
- irregular vaginal bleeding,
- mood changes,
- fatigue, and
- loss of bone density (osteoporosis).
Fortunately, by adding back small amounts of 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 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 [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:
- breast tenderness,
- weight gain,
- irregular uterine bleeding, and
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) 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,
- decreased breast size,
- oily skin,
- hirsutism (male pattern hair growth),
- deepening of the voice,
- 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.
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. They also must be used in combination with other drugs in premenopausal women because of their effects on the ovaries.