Endometriosis : management

Management of endometriosis involves medical therapy and surgical therapy. Endometriosis should only be treated when there is either pain or infertility. Medical therapy for endometriosis may include COCPs (combined oral contraceptive pills), POPs (progestin only pills), DMPA (Depot progestin therapy), LNG-IUS (intrauterine progestin releasing system), GnRH agonists and Danazol. Surgical intervention might be needed when there is indication which include; 1) Endometriosis-related pain not well respond to medical therapy. 2) Endometriosis-related infertility. 3) Pain with ovarian endometrioma.

Under medical therapy COCP,s POPs or DMPA should be considered as the 1st line treatment for managing endometriosis while GnRH agonist with HT(hormone therapy) addback, or LNG-IUS should be considered as the second line therapy.

Each therapy take time to become effective. Analgesia, ranging from NSAIDs (non-steroidal anti-inflammatory drugs) to opioids is commonly prescribed while awaiting resolution of symptoms from the primary medical therapy or surgical therapy. This is to ensure that the patient is more comfortable until the primary treatment becomes effective.

COCPs may be administered as a continuous or cyclic therapy. However continuous therapy is preferred than cyclic therapy since withdrawal bleeding, which occurs with cyclic therapy, usually associated with retrograde menstruation causing the pain symptoms.

POPs may be more effective compared to COCPs in managing endometriosis related pain. However, it may cause breakthrough bleeding and also may lead to systemic effects of progestin such as metabolism and cholesterol abnormalities.

DMPA is effective in relieving pain associated with endometriosis and it gives more long term effect. However, because its progestin effect could not be reversed immediately, there will be a prolonged delay in resumption of ovulation, which is not suitable for women who want pregnancy in the near future, and it may cause prolonged and heavy breakthrough bleeding as well. It is an ideal choice for those with residual endometriosis after hysterectomy done, in which future conception and irregular uterine bleed are not an issue.

One LNG-IUS can provide continuous therapy for 5 years, but the effect can be reversed just by removal of the device. It provides high concentration of progestin in the pelvis and less progestin secreted in to the systemic circulation so that the risk of systemic side effects is reduced. Few risks associated with LNG-IUS include risk of expulsion – 5%, risk of pelvic infection 1.5% and risk of ovarian endometrioma since ovulation is not inhibited.

GnRH agonists is indicated in patient who do not well respond to COCPs or progestins. It induces hypoestrogenism thus effective in managing the pelvic lesions and resolving the pain. GnRH agonists should be used with HT addback in managing endometriosis to avoid the side effects of hypoestrogenism which include hot flashes, insomnia, vaginal dryness ,loss of libido and etc.