Endometriosis Treatment

Treatment options are dictated by the patient's desire for future fertility, her symptoms, the stage of her disease, and to some extent her age. It must be emphasized that therapy for endometriosis requires operative inspection of the lesions for correct diagnosis and staging and to be sure that the patient's symptoms are attributable to endometriosis only.

A. Observation
In asymptomatic patients, those with mild discomfort, or infertile women with minimal or mild endometriosis, expectant management may be appropriate. Although endometriosis is generally felt to be a progressive disease, there is no evidence that treating an asymptomatic patient will prevent or ameliorate the onset of symptoms later. Many reports have found expectant management of infertile women with minimal or mild endometriosis to be as successful as medical or surgical therapies.

B. Analgesic Therapy
Analgesic treatments include nonsteroidal anti-inflammatory agents and prostaglandin synthetase-inhibiting drugs. These drugs are appropriate sole therapy for endometriosis when the patient has mild premenstrual pain from minimal endometriosis, no abnormalities on pelvic examination, and no desire for immediate fertility.

C. Hormonal Therapy
The goal of treatment with hormonal therapy is to interrupt the cycles of stimulation and bleeding of endometriotic tissue. This can be achieved with various agents.

1. Oral contraceptive pills (OCPs) - Generally monophasic products are used and the patient is prescribed 1 pill a day continuously for 6-12 months. The continuous exposure to combination oral contraceptive pills results in decidual changes in the endometrial glands. In cases of breakthrough bleeding additional estrogen may be added. Use of oral contraceptive pills is considered suppressive and not curative in nature. Side effects are breast tenderness, bloating, headache, irritability, and the other side effects associated with oral contraceptive use. Rate of pregnancy following discontinuation of therapy can be as high as 50%.

2. Progestational agents - These agents work via a mechanism similar to that of the OCPs, causing decidualization in the endometriotic tissue. Oral medroxyprogesterone acetate can be prescribed as a 10-30 mg dosage daily. An alternative regimen is megestrol acetate prescribed as a 40-mg daily dose. Depot medroxyprogesterone acetate 150 mg IM can also be given as a single injection every 3 months. Side effects associated with these regimens include irritability, depression, breakthrough bleeding, and bloating. Treatment with progestational agents does not seem to affect pregnancy rates.

3. Danazol - Danazol is a weak androgen that is the isoxazole derivative of 17α-ethinyl testosterone (ethisterone). Danazol acts via several mechanisms to treat endometriosis. It acts at the hypothalamic level to inhibit gonadotropin release, inhibiting the midcycle surge of LH and FSH. Danazol inhibits steroidogenic enzymes in the ovary. As a result a hypoestrogenic environment is created. This, in addition to the androgenic effects of danazol, prevents the growth of endometriotic tissue.