How Is Endometriosis Treated?
Endometriosis is usually a problem as long as a woman menstruates, but treatment can relieve pain and restore fertility. Treatment depends on whether the primary goal is to relieve pain, restore fertility, or both.
Endometriosis can be treated with medication and surgery. Medication interferes with ovulation and the accompanying hormonal changes to relieve pain associated with the implants. The goal of surgery is to remove the endometrial implants and it is generally considered more effective than medical treatment.
A diagnostic laparoscopy may be required before treatment, especially in severe cases or endometriosis that does not respond to initial hormonal treatment. In women with mild or moderate symptoms, an initial hormonal treatment is usually instigated. Many physicians use medication and surgery, usually alternating one with the other. Typically, preoperative medical treatment is followed by postoperative hormonal intervention.
Medications and Hormones
Medical and hormone therapy for endometriosis relieves pain by inhibiting the menstrual cycle and interfering with hormonal fluctuations that stimulate menstruation. Medical treatments include the following:
- Danazol was the first medication approved by the FDA for the treatment of endometriosis and has proven to effectively relieve pain and other symptoms. It does not prevent recurrences, and has many side effects, including weight gain, muscle cramps, decreased breast size, flushing, mood change, oily skin, depression, sweating, edema, acne, hirsutism (abnormal hair growth), decreased libido, headache, dizziness, and deepening of the voice.
- GnRH agonists, or analogs, are a new class of drugs designed to reduce estrogen, which helps shrink the implants and reduces the pain. GnRH analogs are injected or inhaled with a nasal spray. The dosage varies, depending on the specific drug, how it is administered, and the severity of the endometriosis. Common side effects include hot flashes, dryness in the vagina, and a decreased sex drive. GnRH analogs may cause a small amount of bone loss, which is reversible if the medication is discontinued.
- Oral combination birth control pills (OCPs) initiate the shedding of endometrial tissue that normally occurs during menstruation, causing endometrial thinning or apathy that reduces pain associated with endometrial implants. Combination OCPs work about 75% of the time, and because they are less expensive than Danazol or GnRH agonists, they are often a first-choice treatment option. Common side effects include breast tenderness, swelling, weight gain, hypertension (high blood pressure), and blood clots in the legs. Low doses produce fewer side effects.
- Progestins (birth control minipills) create an environment in which there is not enough cell-building estrogen to keep the endometrium thick, thus reducing pain associated with the implants. Progestins are less expensive than OCPs, but they produce more side effects.
- Nonsteroidal antiinflammatory drugs (NSAIDS) may be prescribed to relieve pain, but they do not reduce the size of the implants or treat the source. Due to potentially severe gastrointestinal and cardiovascular side effects, NSAIDs should only be used as instructed.
Surgery is used to treat moderate to severe cases of endometriosis. A laparoscopy is usually the only surgical option for women who want to preserve fertility. In severe cases, however, and in women who choose not to preserve fertility, a laparotomy may be necessary.
A laparoscopy involves making a small incision in the abdomen and inserting an instrument called a laparoscope. The laparoscope allows the doctor to visualize the inside of the abdomen on a monitor. Other surgical tools are inserted through the incision, preventing the need for a larger incision. A laparoscopy can be used to freeze the implants, burn them with a laser, or surgically remove them, depending on the type of lesion.
In a laparascopy done for diagnostic purposes, the lesions are usually removed at the same time.
A laparatomy is major surgery and involves a large incision in the abdomen and a hysterectomy with salpingo-oophrectomy. This procedure relieves endometriosis-related pain, but it may cause other chronic discomfort. It has risks associated with it and a recovery time of 4 to 6 weeks. A laparotomy may be the best option for patients who are suffering debilitating pain.