Mr. R Gazvani, MD, FRCOG

Consultant Gynaecologist

Subspecialist in Reproductive Medicine and Surgery

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How is Endometriosis Treated

In some women, endometriosis causes no symptoms or mild symptoms and does not need to be treated at all. However, untreated endometriosis can continue to worsen, so these women should continue to have regular examinations to monitor the condition.

If endometriosis is causing symptoms or is interfering with a woman’s ability to become pregnant, several treatment options are available:

  • Medication
  • Conservative surgery
  • Hysterectomy

Need To Know:

Medication usually is recommended for women with mild to moderate symptoms. Surgery for endometriosis is usually necessary for women with:

  • Patches of endometrial tissue larger than 1 ½ to 2 inches in diameter
  • Significant adhesions in the lower abdomen or pelvis
  • Endometrial tissue that obstructs one or more fallopian tubes
  • Endometriosis that is causing severe lower abdominal or pelvic pain that can’t be relieved with medication

Which Treatment Is Best for You?

Treatment of endometriosis varies depending on the extent of the condition and a woman’s plans for childbearing.

  • In women with mild to moderate endometriosis, medication can significantly or even completely relieve their symptoms. However, medication cannot cure endometriosis. In some cases, the pain will return about six months after the medication has stopped.
  • In women with moderate to severe endometriosis who wish to preserve their ability to become pregnant in the future, conservative surgery such as laparoscopy would usually be required as well.
  • In women with severe endometriosis who do not wish to have any or additional children, a hysterectomy will offer permanent relief. Hysterectomy also is an option for women with moderate endometriosis who have completed childbearing and women whose symptoms keep coming back after other treatments have been tried.

Need To Know:

Women with endometriosis who want to get pregnant are advised not to delay childbearing for too long, because the repeated scarring and adhesions caused by endometriosis may cause infertility (an inability to conceive). The chances for conceiving are highest in the first two years following treatment for endometriosis.

Medications To Treat Endometriosis

For women with mild to moderate symptoms, medication may be the best treatment option. A course of medication is also sometimes prescribed along with conservative surgery.

Medications to treat endometriosis include:

  • Pain relievers
  • Hormonal treatments
  • Oral contraceptives
  • Progesterone
  • Danazol
  • GnRH agonists

Pain Relievers

Over-the-counter pain relievers may include aspirin, acetaminophen (such as Tylenol), ibuprofen (such as Advil), naproxen sodium, indomethecin, and tolfenamic acid. In some cases, prescription pain-killing medication may be helpful.

Hormonal Treatments

Hormonal treatment is the mainstay of prescription medication for endometriosis. Treatment with medication is based on two important observations:

  • The symptoms of endometriosis tend to improve during pregnancy.
  • The symptoms of endometriosis tend to improve after menopause .

From these observations, two treatments have evolved:

  • Pseuodopregnancy medical therapies, which are drugs that fool the body into thinking it is pregnant. These include oral contraceptives and progesterone.
  • Pseudomenopause medical therapies, which are drugs that fool the body into thinking that it is past menopause. These include danazol and GnRH agonists.

Oral Contraceptives

When it was introduced, pseudopregnancy therapy (fooling the body into thinking it is pregnant) with high-dose birth control pills was an important advance in the treatment of endometriosis. This approach is used less now, since the introduction of other treatments.

However, in some women, oral contraceptives (birth-control pills) are the best option. The type of oral contraceptive used is the combination birth control pill (which contains two female hormones, estrogen and progestin).

Oral contraceptives cannot cure endometriosis, but they can be effective in temporarily relieving the pain. They do this by stopping the monthly hormonal cycle, which causes the endometrial tissue to swell.

Minor side effects include abdominal swelling, breast tenderness, increased appetite, ankle swelling, nausea, and bleeding between periods. In rare cases, oral contraceptives can cause deep vein thrombosis (blood clots).

Need To Know:

Research has proven that smoking and taking oral contraceptives (birth control pills) significantly increases a woman’s risk for stroke. Together, they can cause blood clots to form. Women who smoke should not take oral contraceptives.

Progesterone

Progesterone is one of the female sex hormones produced by the ovary that prepares the lining of the uterus for implantation of a fertilized egg. Given orally or by injection, progesterone induces a simulated state that mimics pregnancy. This relieves the symptoms of endometriosis by stopping the monthly swelling and discharge of the endometrial tissue.

Progestogens (drugs with properties similar to progesterone) that are used for treating endometriosis include medroxyprogesteron acetate, norethisterone, and norgestrel. Many women respond well to this treatment, but some experience side effects that include:

  • Irregular menstrual bleeding (a common side effect)
  • Weight gain
  • Acne
  • Mood swings
  • Depression

Danazol

Since its introduction in 1971, danazol has become the main drug treatment for endometriosis.

Unlike oral contraceptives and progesterone, which induce a pregnancy-like state, danazol is a synthetic male hormone that relieves the pain of endometriosis by temporarily stopping the monthly hormonal cycle that causes endometrial tissue to swell.

Although it is true that danazol is a synthetic hormone, it can be thought of as an “anti-hormone,” since many of its actions oppose the effects of estrogen, the main female hormone. Although danazol does not increase the total amount of testosterone (male hormone) in a woman’s body, it renders it more biologically active.

Need To Know:

Because danazol can be harmful to a fetus if taken during pregnancy:

  • A woman should begin taking it on the first day of a period to ensure that she is not pregnant, and
  • A woman and her partner should use effective birth control methods to ensure a pregnancy does not occur while she is taking danazol.

Danazol is a very effective medication; it improves the symptoms of endometriosis in more than 95 percent of the women who take it. It is usually taken for six months. However, danazol can produce a number of side effects, including:

  • Acne
  • Greasy skin
  • Weight gain
  • High cholesterol levels
  • Increase in body hair growth
  • Voice changes
  • Disruption of menstrual cycle
  • Hot flushes and sweats
  • Reduced sex drive
  • Indigestion and stomach upsets
  • Dizziness
  • Reduced breast size
  • Muscle cramps
  • Irritability
  • Headaches
  • Tiredness

However, only a small percentage of women (5 to 10 percent) chose to discontinue danazol because of side effects. Most do not experience major problems and can complete the course of treatment. Women who become pain-free while on danazol often feel very well.

Treatment with danazol usually lasts six to nine months. Any side effects from danazol are reversible, and women will often tolerate them in exchange for the relief of the pain caused by endometriosis. When the medication is stopped, a woman’s fertility (ability to become pregnant) returns in two to three months.

Need To Know:

Danazol should not be taken by:

  • Women who are or may be pregnant
  • Women who are breast-feeding
  • Women with occupations dependent on voice quality, such as singers, because there is a small risk of voice changes

Also, women who experience migraine headaches should be aware that the migraines might worsen during treatment.

GnRH Agonists

GnRH agonists is an abbreviation for gonadotropin-releasing hormone analogues. The role of this group of drugs is to suppress the pituitary gland .

The pituitary gland normally produces hormones that act on the ovary, which in turn produces the female sex hormones, estrogen and progesterone. By “turning off” the pituitary, the ovary is also “turned off.” As a result, the ovaries stop ovulating and no longer produce estrogen. The overall effect is termed “medical menopause.”

This group of drugs is proven to be effective in treating endometriosis, but they also tend to produce side effects that include:

  • Vaginal dryness
  • Mood swings
  • Hot flashes (a more common side effect)

Unlike danazol, they do not raise cholesterol levels. But they do cause calcium loss from bone, which can result in osteoporosis . Less common side effects include decreased sex drive, reduced breast size, bloating, and excess hair growth.

The GnRH agonists (known also as GnRH analogues) are given as a monthly injection or daily nasal spray and have become a popular (although more expensive) alternative to danazol. These drugs include Lupron, Synarel, and Zoladex.

As with danazol, GnRH agonists should not be taken during pregnancy, so effective contraception methods should be used. A woman’s menstrual period will resume about two months after discontinuing the medication, and fertility usually returns in one to two months.

Conservative Surgery

Surgery may be considered for women with severe pain whose symptoms are not relieved with medication. For these women, the treatment can be tailored depending on whether they want to be able to have children. Conservative surgery can help preserve a woman’s ability to become pregnant.

Conservative surgical procedures include:

  • Laparoscopy
  • Laparotomy
  • Laser surgery
  • Electrocautery

Conservative surgery for endometriosis is performed to remove areas of endometriosis and to divide adhesions without removing the uterus or the ovaries. It is offered to women who wish to be able to have children in the future.

One problem with conservative surgery is that it usually provides only a temporary measure of relief, as endometriosis recurs in most women.

Nice To Know:

Very often, conservative surgery will be performed after a course of danazol or GnRH agonists, as the results of surgery tend to be better.

Laparoscopy

When a laparoscopy is done to confirm a diagnosis of endometriosis, the endometrial tissue can be removed at the same time. Laparoscopy is performed by inserting a pencil-thin instrument through an incision in the abdomen (usually in the belly button). It gives the physician an exceptionally clear view, on a television monitor, of the inside of the abdominal cavity.

The physician can pass other instruments through the same incision, or through other tiny incisions, to remove the misplaced endometrial tissue.

Laparotomy

In laparotomy, an incision is made in the abdomen and the abdominal cavity is opened and explored for signs of disease. Any endometrial tissue is removed, and the incision is then closed.

Laparotomy is major surgery that requires a brief hospital stay and three to four weeks of recuperation afterwards. This procedure is not performed as commonly as laparoscopy.

Laser Surgery

A laser is a device that concentrates light into an intense beam to produce heat that can destroy misplaced endometrial tissue. A variety of lasers can be used for treating endometriosis during laparoscopy. Although laser surgery is an important advance, it has not been shown to be superior or safer than other laparoscopic methods that destroy tissue, such as the use of electrical probes or direct heat.

Electrocautery

This procedure uses an electrical current to produce heat and destroy the patches of endometrial tissue. As with laser surgery, electrocautery is performed during laparoscopy.

Hysterectomy

Hysterectomy, the most radical treatment for endometriosis, involves surgically removing the uterus, both ovaries and both fallopian tubes, along with as many areas as possible of misplaced endometrial tissue.

A hysterectomy can be performed by making a cut (incision) in your abdomen, which exposes the organs and tissues that need to be removed. This is called an abdominal hysterectomy. During the procedure, a woman will have general anesthesia and will be asleep.

A hysterectomy also can be performed through the vagina (vaginal hysterectomy), which eliminates the need for an abdominal incision. However, in women with endometriosis, an open incision allows the surgeon the opportunity to better view the abdominal cavity to look for and remove areas of endometriosis.

The major advantage of hysterectomy is that it is very effective, and recurrences of endometriosis are rare. After a hysterectomy, a woman will no longer have menstrual periods and may experience symptoms of menopause. However, those symptoms can be controlled with hormone replacement therapy and other medication.

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