Medical management of endometriosis
- Kirsten Black, Ian S Fraser
- Aust Prescr 2012;35:114-7
- 1 August 2012
- DOI: 10.18773/austprescr.2012.050
Endometriosis is increasingly being recognised as a disease which commonly affects women through the reproductive years.
It is the commonest cause of chronic pelvic pain in developed countries, and frequently begins in adolescence.
Endometriosis is a highly variable condition, and diagnosis can be difficult. Confirmation of diagnosis still requires laparoscopy in most situations, but successful therapy of many, especially milder, cases can be based on a presumptive diagnosis. A careful history needs to be taken to try and exclude other common causes of pelvic pain.
Medical management requires treatment of pain with analgesics, and suppression of disease activity mainly with hormonal preparations. This needs to be integrated with the potential need for surgery.
Patients with persistent pain unresponsive to hormonal treatments and analgesics should be referred for specialist care.
Box 1 - Variable factors leading to a heterogeneous clinical picture of endometriosis
Box 2 - Symptoms suspicious of endometriosis
Box 3 - When to refer women for specialist opinion
Table 1 - Treatment options for endometriosis (in addition to necessary analgesia)
The management of endometriosis may be influenced by the woman’s presenting complaint, for example pain or infertility.
Endometriosis is a chronic condition that may require lifelong management. Medical treatment is usually based on suppressing ovulation and inducing a steady hormonal environment. Commonly used drugs and their mechanisms of action are listed in Table 1 . Both oral progestogens and combined oral contraceptives may be effective in relieving pain. They are generally well tolerated and are initially preferable to danazol, gonadotrophin releasing hormone agonists and aromatase inhibitors.10 In our clinical experience, in most women progestogen-only methods that induce decidualisation of the endometrial lesions are more effective than combined oral contraceptives. There is a trend towards use of the delivery systems like the levonorgestrel intrauterine system, which has evidence of efficacy,11, 12 and the subdermal etonogestrel implant, where the benefit has been documented so far mainly in case reports. It is not logical to give an oestrogen-containing preparation (combined oral contraceptive) to a woman with an oestrogen-sensitive disease, but all modern combined oral contraceptives have a strong progestogenic balance and many women do well with this treatment. There is no evidence that one combined oral contraceptive is superior to another.
In a woman wishing to conceive, medical treatment will relieve symptoms but there is strong evidence that it does not improve fecundity. The recommended approaches are surgical excision of macroscopically recognisable lesions on the peritoneal surface, deep lesions or ovarian cyst linings by a specialist, or referral for assisted fertilisation techniques.13
Endometriosis has a propensity to recur with time after conservative surgery (excision of visible lesions, rather than removal of the ovaries and uterus). At least 10–20% of treated patients developed signs and symptoms of persistent or recurrent endometriosis within one year.16
There is good evidence that hormonal treatments after surgery reduce symptoms and disease recurrence. The combined pill and oral progestogens have been found to reduce the frequency and severity of recurrent endometriosis-related dysmenorrhoea17 and endometriomas after surgery.18 Local pelvic release of levonorgestrel via an intrauterine system is an effective way of delivering progestogen therapy and has been found to be as effective at relieving dysmenorrhoea as gonadotropin releasing hormone agonists19 or injectable progestogens, without the same degree of systemic symptoms.20 The role of the subdermal etonogestrel implant in this situation has not yet been clarified.
If recurrence occurs, initial treatment should be appropriate analgesics and hormonal treatment. Repeat surgery has the same limitations as primary surgery in terms of disease recurrence. In the most severe and troublesome symptomatic endometriosis, combined off-label use of the two progestogen delivery systems (levonorgestrel intrauterine system and etonogestrel subdermal implant used simultaneously) may have a major beneficial impact on quality of life, but there is only one case report to support this line of management.21 It also needs to be recognised that a minority of severe endometriosis sufferers experience persistent pelvic pain, which has a major impact on quality of life. Ongoing management may require involvement of a specialised pain management clinic.
Senior lecturer, Department of Obstetrics, Gynaecology and Neonatology, University of Sydney
Professor in Reproductive Medicine, Division of Women’s and Children’s Health, Royal Prince Alfred Hospital, Sydney