Endometriosis affects over 70 million women and girls world-wide (Endo Resolved). It is common among women of reproductive age, approximately 15%. On average it takes 7 years from the time symptoms appear to diagnosis and finally treatment. Women suffering from endometriosis experience chronic pelvic pain and loss of time and productivity from work and school. Some women of child bearing age also experience infertility (Ryan). Currently there are no cures for endometriosis. Treatments attempt manage pain relief and slow the progression of endometriosis (Ryan).
The main goal of the treatment is to relieve the symptoms of pelvic pain, infertility, and pelvic mass associated with endometriosis. This accomplished using medical/drug therapies, surgical intervention, and combined therapies. There are a number of factors taken into consideration when deciding on what treatment method is best and is individualized for each woman. Often, a woman’s desire to bear children is a key decision maker. Other factors are age, severity of symptoms, stage of the disease and its location, prior treatments, and cost (Schenken).
Endometriosis is often diagnosed during a laparoscopy, a diagnostic surgical procedure in which a lighted optical tube is inserted into the navel through a small incision. Using a laparoscope, the doctor will be able to view the presence of endometrial lesions or implants on the outside of uterus, ovaries, fallopian tubes, endometrial tissue, bowel, and/or appendix (Rushall, Cleveland Clinic). A variety of medical or drug therapies are available. Therapy choice is generally dependent on severity of the endometriosis and symptoms, as well as cost.
Initial medical therapies include analgesics, such as non-steroidal anti-inflammatory drugs, and oral contraceptive pills. If these are not effective, hormonal interventions may be prescribed. Non-steroidal anti-inflammatory drugs (NSAIDS) are commonly prescribed for those with minimal pain. It is an effective treatment for those suffering from menstrual cramps (primary dysmenorrheal). Advantages to taking NSAIDS are they readily available, cost-effective, and cause minimal side-effects (Schenken).
Oral contraceptive pills (OCPs) are commonly used for women with minimal to mild symptoms, also offering relief of menstrual cramps (Schenken). Although OCPs contain estrogen, which often stimulates endometriosis, pain relief is often experienced (Ryan). OCPs work by “inducing decidualization, or shedding, subsequent atrophy, and has shown conflicting evidence it can slow the progression of the disease. ” The advantages to OCPs it will allow for the possibility of pregnancy in the future and can be taken for an indefinite period of time (Schenken).
The three most common hormonal interventions used when NSAIDs and OCPs to do not provide enough relief and/or there is recurrent mild endometriosis and pain are: gonadotropin-releasing hormone (GnRH) agonist analogs, danazol, and progestins. Hormonal interventions alter a woman’s estrogen/progesterone levels. Hormonal treatments target the ovarian estrogen production or antagonized estrogen action, affecting the growth of endometriosis (Schenken). Gonadotropin – releasing hormone (GnRH) agonists are used for the treatment of moderate to severe pain associated with endometriosis to induce a state of “pseudomenopause”.
GnRh agonists have been the most studied treatment for endometriosis (Ryan). Trials have shown that GnRH agonists are effective pain relievers in addition to reducing the size of endometriosis implants. A disadvantage of GnRH agonists is bone loss (Schenken). Under its FDA approval, GnRH can be prescribed for 6 months if it is used without an “add-back” therapy. Add-back therapy is hormone replacement to protect bone density and “to ameliorate vasomotor symptoms. ” It can be extended for additional 6 months if used in conjunction with an “add-back” therapy (Ryan).
Androgens such as Danazol are also FDA approved for treating endometriosis. Andogrens were more commonly used in the past prior to the newer medical and surgical options (Ryan). Danazol is “effective in resolving implants when treating mild or moderate stages of the disease. ” 80% of women report improvement of pain or relief within two months of treatment. Danazol also induces a state of “pseudomenopause” by inhibiting the secretion of pituitary gonadotropin. It directly inhibits the growth endometriotic implants and of ovarian enzymes responsible for estrogen production.
Disadvantages or side effects of danazol are: weight gain, muscle cramps, decreased breast size, acne, hirsutism, oily skin, decreased high density lipoproteins levels (which can be detrimental), increased liver enzymes, hot flashes, mood swings, and depression (Schenken). Other side effects include undesirable hair growth and deepening of the voice, in some women irreversible, and have limited the use of these medications (Ryan). Progestins are often used as side line treatment option after GnRH agonists. It is an effective hormonal treatment method with 80% of women experience partial or complete pain relief while taking progestins.
Estrogen hormonal progestin mimics pregnancy. They inhibit endometriotic tissue growth by initially causing decidualization and the atrophy. They also inhibit pituitary gonadotropin secretion and ovarian hormone production. Advantages to taking progestins are: more cost effective than GnRH agonists and can be taken indefinitely. Disadvantages range from weight gain, irregular uterine bleeding/spotting, and mood changes (Schenken). A new promising treatment option for women experiencing severe endometriosis is the use of aromatase inhibitors.
While not currently approved for the treatment of pelvic pain caused by endometriosis, it “appears to regulate local estrogen formation within the endometriotic lesions themselves and inhibit estrogen production in the ovary, brain, and periphery. ” Disadvantages include significant bone loss with prolonged use and cannot be used a single agent in premenopausal women because they stimulate the release of the Follicle Stimulating Hormone and cause multi-follicular cyst development (Schenken). Surgery may be required in cases of advanced stages of endometriosis and where endometrias are suspected.
Advantage to early surgical intervention is avoidance of the expense and side effects of medical treatment (Schenken). Often times, the initial diagnostic laparoscopy provides an opportunity for conservative surgical treatments, such as the ablation or excise of implants and adhesions (Schenken). Ablation refers to the burning away of endometrial lesions by a high-energy heat source such as a laser. Excise is the cutting away of the lesions (Cleveland Clinic). This can delay and/or prevent the disease or symptom progression. It has also been found to help some patients who experienced endometriosis-associated infertility.
Most patients who undergo laparoscopic ablation/excision achieve pain relief. However, there is a recurrence rate of 40% at the ten year follow-up appointment and about 20% of patients will undergo an additional surgery within two years. Laparotomy is also considered a conservative surgery. It is performed when there are extensive adhesions or invasive endometriosis located near the uterine arteries, uterer, bladder, and bowel (Schenken).
Definitive surgery, such as a hysterectomy, is considered when 1) incapacitating symptoms persist ollowing conservative surgery and medical therapy, 2) moderate to severe disease is present and future pregnancy is not desired, or 3) hysterectomy is indicated for coexisting pelvic pathology. Age and child-bearing potential are often the primary decision factors for undergoing a hysterectomy. Young women who undergo hysterectomy are more likely to report residual symptoms, a sense of loss, and overall disruption in their life than older women. The ovaries in young women will try to be preserved so as to avoid premature development of menopausal symptoms and decision-making regarding estrogen replacement.
When the ovaries are extensively damaged by endometriosis or the woman is nearing the age of menopause, the ovaries will be removed. If a hysterectomy is performed, the doctor should discuss estrogen replacement therapy with the patient (Schenken). Combination of medical and surgical therapy may be also recommended. In preoperative medical therapy, the size of the endometriotic implant(s) may be decreased with the use of hormone suppression medications. This can reduced the extent of surgery required. Other times postoperative medical treatment is necessary.
Progestins, danazol, estrogen-progestin pills, and GnRH agonists will be used in conjunction with laparotomy or laparoscopic conservative or definitive surgical treatment. Postoperative medical therapy can increase the length of pain relief and delay the recurrence of the disease (Schenken). The methods of treatment discussed thus far have been Western medicine’s approach to endometriosis. According to Traditional Chinese medicine (TCM) endometriosis is due to a woman’s poor blood circulation.
Its focus is to increase circulation by “smoothing the channel, or pathway, that supplies blood to the body. Acupuncture helps relieve pain and believed to balance the body’s hormones. Acupuncture needles are strategically inserted to points that “influence the nervous system, organ functions, and endocrine system, therefore restoring balance and improving blood circulation. TCM believe that the liver and kidneys are the two most important organs regarding fertility and menses (Rushall). Even in Western medicine acupuncture is considered an “effective, safe, and well-tolerated therapy for endometriosis-related pelvic pain in adolescents” (Schenken).
For the 70 million women and girls world-wide, the goal of endometriosis treatment is to relieve symptoms associated with pelvic pain, pelvic mass, and infertility. The appropriateness of treatment methods are individualized to each woman. Non-steroidal anti-inflammatory drugs and oral contraceptive pills are prescribed to women experiencing minimal to mild endometriosis associated menstrual cramps. Hormonal therapies target the ovarian estrogen production, thus altering the estrogen/progesterone profile.
Gonadotropin-released hormone agonists, the androgen Danazol, and Progestin are prescribed for recurrent mild endometriosis and/or for moderate to severe pain. Aromatase inhibitors are a promising treatment method for severe endometriosis. Surgical intervention may be necessary for some patients. This includes ablation and/or excision, which can be performed during a diagnostic laparoscopy, a laparotomy, and partial or complete hysterectomy. Acupuncture is more commonly being used for the management of pain. All treatment methods attempt to manage pain and slow the progression of endometriosis.