While there is no cure for endometriosis, in many patients menopause (natural or surgical) will abate the process. In patients in the reproductive years, endometriosis is simply managed: the goal is to provide pain relief, to restrict progression of the process, and to relieve infertility if that should be an issue. In younger women with unfulfilled reproductive potential, surgical treatment tends to be conservative, with the goal of removing endometrial tissue and preserving the ovaries without damaging normal tissue. In women who do not have need to maintain their reproductive potential, hysterectomy and/or removal of the ovaries may be an option; however, this will not guarantee that the endometriosis and/or the symptoms of endometriosis will not come back, and surgery may induce adhesions which can lead to complications.
In general, patients are diagnosed with endometriosis at time of surgery, at which time ablative steps can be taken. Further steps depend on circumstances: patients without infertility can be managed with hormonal medication that suppress the natural cycle and pain medication, while infertile patients may be treated expectantly after surgery, with fertility medication, or with IVF.
Sonography is a method to monitor recurrence of endometriomas during treatments.
Treatments for endometriosis in women who do not wish to become pregnant include:
Hormonal medication
- Progesterone or Progestins: Progesterone counteracts estrogen and inhibits the growth of the endometrium. Such therapy can reduce or eliminate menstruation in a controlled and reversible fashion. Progestins are chemical variants of natural progesterone.
- Avoiding products with xenoestrogens, which have a similar effect to naturally produced estrogen and can increase growth of the endometrium.
- Hormone contraception therapy: Oral contraceptives reduce the menstrual pain associated with endometriosis. They may function by reducing or eliminating menstrual flow and providing estrogen support. Typically, it is a long-term approach. Recently Seasonale was FDA approved to reduce periods to 4 per year. Other OCPs have however been used like this off label for years. Continuous hormonal contraception consists of the use of combined oral contraceptive pills without the use of placebo pills, or the use of NuvaRing or the contraceptive patch without the break week. This eliminates monthly bleeding episodes.
- Danazol (Danocrine) and gestrinone are suppressive steroids with some androgenic activity. Both agents inhibit the growth of endometriosis but their use remains limited as they may cause hirsutism and voice changes.
- Gonadotropin Releasing Hormone (GnRH) agonist: These agents work by increasing the levels of GnRH. Consistent stimulation of the GnRH receptors results in downregulation, inducing a profound hypoestrogenism by decreasing FSH and LH levels. While effective in some patients, they induce unpleasant menopausal symptoms, and over time may lead to osteoporosis. To counteract such side effects some estrogen may have to be given back (add-back therapy). These drugs can only be used for six months at a time.
- Lupron depo shot is a GnRH agonist and is used to lower the hormone levels in the woman's body to prevent or reduce growth of endometriosis. The injection is given in 2 different doses a once a month for 3 month shot with the dosage of (11.25 mg) or a once a month for 6 month shot with the dosage of (3.75 mg).
- Aromatase inhibitors are medications that block the formation of estrogen and have become of interest for researchers who are treating endometriosis.
Other medication
- NSAIDs Anti-inflammatory. They are commonly used in conjunction with other therapy. For more severe cases narcotic prescription drugs may be used. NSAID injections can be helpful for severe pain or if stomach pain prevents oral NSAID use.
- MST Morphine sulphate tablets and other opioid painkillers work by mimicking the action of naturally occurring pain-reducing chemicals called endorphins. There are different long acting and short acting medications that can be used alone or in combination to provide appropriate pain control.
- Diclofenac in suppository or pill form. Taken to reduce inflammation and as an analgesic reducing pain.
Surgery
Procedures are classified as
- conservative when reproductive organs are retained,
- semi-conservative when ovarian function is allowed to continue, and
- radical when the uterus and ovaries are removed.
Conservative therapy consists of removal, excision or ablation of endometriosis, adhesions, resection of endometriomas, and restoration of normal pelvic anatomy as much as is possible.
For patients with extreme pain, a presacral neurectomy may be indicated where the nerves to the uterus are cut. However, strong clinical evidence showed that presacral neurectomy is more effective in pain relief if the pelvic pain is midline concentrated, and not as effective if the pain extends to the left and right lower quadrants of the abdomen.
- Has increased efficacy over medicinal intervention for infertility treatment
- Combined with biopsy, it is the only way to achieve a definitive diagnosis
Disadvantages of surgery
- Cost
- Risks are "poorly defined... and probably underestimated." In one study, 3-10% experienced major complications from surgery.
- Efficacy is questionable. In the same study, substantial short-term pain relief was experienced by approximately 70-80% of the subjects. However, at 1 year follow-up, approximately 50% of the subjects needed analgesics or hormonal treatments. The use of medical suppression after surgery for minimal/mild endometriosis has not shown benefits for patients with infertility. as do omega 3 fatty acids, particularly EPA. The use of soy has been reported to both alleviate pain and to aggravate symptoms, making its use questionable.
- Physical therapy for pain management in endometriosis has been investigated in a pilot study suggesting possible benefit. Physical exertion such as lifting, prolonged standing or running does exacerbate pelvic pain. Use of heating pads on the lower back area, may provide some temporary relief.
Further Reading
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"Endometriosis"
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