Main problems during endometriosis are menstrual pain, pelvic pain and infertility. The treatment options available to women who have been diagnosed with endometriosis is mostly depend on the type and severity of the symptoms and whether the patient is seeking treatment because of infertility or to relieve the pain and discomfort of her endometriosis symptoms.
Most types of treatment are targeted according to the most common symptoms of endometriosis. Endometriosis can be treated with medications and/or surgery. The goals of endometriosis treatment mainly include pain relief and/or treatment of fertility.
For women who are experiencing mild symptoms, a course of oral contraceptives or progestin is often first prescribed and the effectiveness of the medication in relieving pain and discomfort is then assessed. A recent strategy is to treat with a 3 month trial of GnRH, a hormone that inhibits gonadotropin secretion. If these treatments prove to be ineffective, other options can then be considered.
Endometriosis treatment with danazol
ENDOMETRIOSIS PAIN MEDICATION
Nonsteroidal anti-inflammatory drugs (so called “NSAIDs”) such as ibuprofen (Motrin or Advil) or naproxen sodium (Aleve) 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.
If NSAIDs are not sufficient for pain control, your doctor can prescribe stronger medications, even including opioid (narcotic) drugs. Care should be taken when using these drugs due to the possibility for abuse and addiction.
Other medical treatment options are available for women who experience dysmenorrhea (painful and heavy periods) or dyspareunia (pain during or after sexual intercourse). Unfortunately pain medications have no affect on infertility caused by endometriosis.
ENDOMETRIOSIS HORMONE THERAPY
Depending on the severity of the disease, the next step in the treatment of endometriosis is to slow or halt the proliferation of the endometrial tissue outside of the uterus. Different treatment strategies may be employed to change the hormone levels that promote endometriosis. Effectiveness of hormonal therapy depends on type and extent of endometrial implants.
In general hormone therapy is effective if endometriosis areas are small and/or patient has minimal pain. Hormones can come in pill form, by shot or injection, or in a nasal spray.
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. Common hormones used to treat endometriosis pain are progesterone, birth control pills, danocrine, and gonadatropin-releasing hormone (GnRH).
These medications are not for all women. As with most medications, there are some side effects linked to hormone treatment. Some women may find the relief of pain is worth the side effects. These medications do not relieve pain in all women.
Gonadotropin-releasing hormone analogs (GnRH analogs)
Gonadotropin-releasing hormone is a hormone that helps control the menstrual cycle. GnRH agonists are drugs that are like human GnRH but many times stronger than the natural substance. They lower estrogen levels by turning off the ovaries. This causes a short-term condition that is much like menopause.
Gonadotropin-releasing hormone analogs (GnRH analogs) may be prescribed to relieve pain and reduce the size of endometriosis implants. GnRH analogs are administered by nasal spray or by intramuscular injections at one to three month intervals. These drugs suppress estrogen production by the ovaries, resulting in a cessation of menstrual periods, and symptoms mimicking those of the menopausal transition including hot flashes, vaginal dryness, irregular vaginal bleeding, mood changes, fatigue, and loss of bone density (osteoporosis). Fortunately, many of the annoying side effects due to estrogen deficiency can be avoided by administering small amounts of estrogen and progesterone in pill form.
Treatment with GnRH most often lasts at least 3 months. To help reduce the amount of bone loss from long-term use, your doctor may prescribe certain hormones or medications to take along with GnRH agonists. In many cases, this therapy also may reduce other side effects. After stopping GnRH treatment, you should have periods again in about 6–10 weeks.
Birth control pills
Birth control pills (so called oral contraceptives) are also sometimes used to treat endometriosis. Birth control pills prevent ovulation; they directly have a thinning effect on endometrial tissue. Because all endometrial tissue in the body is affected, this has the effect of relieving pain and reducing the volume of menstrual flow, thus giving relief to the patient. Because of the limited side-effects, this treatment is able to be continued in the long-term, at least until pregnancy is desired.
Birth control pills often are prescribed to treat symptoms of endometriosis. The hormones in them help keep the menstrual period regular, lighter, and shorter and can relieve pain. Sometimes women who have severe menstrual pain are asked to use birth control pills continuously (non-stop – skipping the placebo sugar pills). 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. Birth control pills are usually well-tolerated in women with endometriosis.
Progestins also can be used to shrink endometriosis. Progestin works against the effects of estrogen on the tissue. Although you will no longer have a monthly menstrual period when taking progestin, you may have irregular vaginal bleeding. Progestin is taken as a pill or injection.
Progestins (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.
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.
This type of treatment very often includes some side effects – breast tenderness, bloating, weight gain, irregular uterine bleeding, and depression.
Danazol has been very effective in addressing and relieving endometriosis symptoms, but it has some negative side-effects which make it a less attractive choice. This drug is taken for a 6 month period, although the time can be extended to 9 months if the treatment is tolerated and effective.
Danazol (Danocrine) is a synthetic drug that creates a high androgen (male 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, edema, decreased breast size, acne, oily skin, hirsutism (male pattern hair growth), deepening of the voice, headache, 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.
If treatment with medications does not work or is not appropriate for a woman, surgery can be considered if she has severe pain or severe damage to the pelvic structures.
While surgery is invasive and more expensive, it may have improved long-term results than medication, is the only option for treating infertility caused by endometriosis and is able to give a definitive and accurate diagnosis. The main benefit of surgery to women with fertility problems related to endometriosis is that often the surgical removal of misplaced endometrial tissue will remove the cause of their infertility. In fact, a recent study has shown that even patients with mild endometriosis had a 13% increase in pregnancy probability.
Surgical treatment is the best choice if your endometriosis is extensive, or if you have more severe pain. Surgical treatments range from minor to major surgical procedures.
* Laparoscopic surgery (a minimally invasive, camera-guided surgical procedure) may be used in an attempt to remove all endometrial tissue outside of the uterus. This removal is often performed during the surgery when endometriosis is diagnosed. During laparoscopy, endometriosis can be removed or burned away.
* Surgery to remove the uterus and ovaries, called a hysterectomy, is considered for women who fail medical therapy and no longer wish to have additional children.
Although surgery can be very effective, endometriosis may recur following surgery. Some studies have shown the recurrence rate of endometriosis following surgical treatment to be as high as 40%.
A newer approach to the treatment of endometriosis has involved the administration of drugs known as aromatase inhibitors – 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 and cannot be used alone without other medications in premenopausal women because they stimulate development of multiple follicles at ovulation.
Aromatase inhibitors cause significant bone loss with prolonged use. A further drawback is that these drugs stimulate development of multiple follicles at ovulation, so they must be used with caution in premenopausal women and may be combined with another medication such as a GnRH agonist or oral contraceptive pill to suppress the development of follicles.
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