Endometriosis Treatements and Management

The treatment of endometriosis is widely classified into pharmacological and surgical methods. Since the etiology of the disease is not well defined, none of the currently available treatments can prevent or treat endometriosis. Rather, the treatment is primarily aimed at providing relief from symptoms or improving fertility rates. Therefore, consideration should be given to how treatment options affect pain levels and infertility when studying whether endometriosis treatment improves quality of life

It is imperative that each patient be treated according to his symptoms and aspirations. For example, infertility does not need to be addressed unless a patient wishes to conceive and deep infiltrating disease does not need to be removed if it does not cause problems. For these reasons, the first principle of endometriosis treatment is to take a complete and detailed history and plan the treatment based on the symptoms

Endometriosis Treatment

Therapeutic aims 
• What are you treating (disease, symptoms or both)?
• Why are you trying?

• Possible reasons to treat
• Improvenatural fertility
• Enhance chances of success at ART
• Pain relief as an alternative to surgery
• Pain relief while awaiting surgery
• Adjunct to surgery
• Prophylaxis against the appearance of diseases
• Recurrence of symptoms

Pharmacological Treatment

First choice Drug Treatments
First-line therapy for pain associated with endometriosis includes NSAIDs, AO or a combination of both. These classes of drugs are considered effective and less expensive than other endometriosis treatments

Nonsteroidal anti-inflammatory drugs do not treat endometriotic lesions, but can be effective in treating pelvic pain. In particular, the pain associated with dysmenorrhea is mediated by the synthesis of prostaglandins1. Nonsteroidal anti-inflammatory drugs inhibit cyclooxygenase and therefore reduce the production of prostaglandins and reduce pelvic pain

Hormonal Treatments
Traditionally, hormonal treatments have attempted to mimic pregnancy or menopause, based on the clinical impression that the disease recedes during these physiological states. Currently available treatments, combined oral contraceptives (COCs), progestogens, danazol, gestrinone and gonadotropin releasing hormone (GnRH) agonists have been extensively reviewed

Despite the different modes of action, they seem to induce atrophy and decidualization of peritoneal deposits by suppressing ovarian function. Peritoneal lesions decrease in size during therapy but reappear quickly after therapy; DIE responds in a similar way. Endometriomas rarely decrease in size and adhesions will not be affected

Long-term therapy

• Progestini
• Oral contraceptives

Short-term therapy

• Danazol
• GnRH agonists

Oral Contraceptives
Estrogen-progestagen combination contraceptive pills are commonly used to control pelvic pain and dysmenorrhea related to endometriosis. These agents were initially used to maintain a "pseudo pregnancy regime" to relieve symptoms. Cyclic use of oral contraceptives is the only treatment for endometriosis that allows for regular uterine bleeding. However, since dysmenorrhea is an important symptom of endometriosis, regular use of oral contraceptives has a limited advantage. Continuous use is most effective in the treatment of pelvic pain

Progestins
A variety of progestogens (progestagens) alone have been used in the medical treatment of endometriosis in an attempt to reduce the side effects associated with the estrogenic component of oral contraceptives. As described above, it has been proposed that progestogens inhibit endometriotic implants causing an initial decidual reaction, which presumably would entail a possible atrophy

Gonadotropin releasing hormone agonists
The most predictable form of medical therapy that inhibits the production of estrogen by the ovaries is the GnRH agonist. Continuous exposure to GnRH leads to a hypogonadic state with reduced release and suppression of estradiol from the ovaries. GnRH agonists bind to the receptors of the pituitary gland, which initially causes a release of the follicle-stimulating hormone (FSH) and luteinizing hormone (LH), followed by modulation, a decrease in gonadotropin secretion and, finally, the cessation of the production of ovarian estrogens

Danazol
Androgens are steroid hormones that promote male secondary sexual characteristics. Danazol is an androgen which is commonly used for the treatment of endometriosis. It is a derivative of 17α-ethinyltestosterone, which inhibits steroidogenesis and increased LH, thereby increasing free testosterone levels

Surgical Treatment

Surgical treatment is no longer a first-line therapy. Surgery is indicated in patients who have failed medical therapy and who have physical results of extensive endometriosis such as endometriomas. Ovarian cystectomy, oophorectomy, hysterectomy and total hysterectomy are radical options which, although often curative, are not suitable for women who want to preserve fertility

The goals of surgical treatment are to eliminate endometriomas, relieve pain and improve fertility rates through adesiolysis. Laparoscopy is the preferred surgical approach for the treatment of endometriomas. Laparoscopy is associated with shorter hospitalizations, faster recovery, less use of painkillers, reduced costs and less damage to a patient's ovarian reserve when a subsequent ovarian procedure is performed

When to use Surgical or Medical Treatment (Drug Treatment)?

Medical treatment is based on hormonal manipulation of the ovarian cycle and exerts an effect by inducing amenorrhea. All types of medical treatments, with the exception of pain relievers, are effective in reducing the pain associated with endometriosis, but their side effect profile limits their long-term use and recurrence is common in stopping. Medical treatment does not improve fertility and is contraceptive. If fertility is the priority, conservative surgery is effective in reducing pelvic pain associated with endometriosis and improving the chances of pregnancy

Endometriosis Management

Endometriosis is a long-term chronic disease; Repeated therapy is necessary to treat the symptoms and limit their recurrence. However, the side effects of long-term therapy should also be considered. Treating women with endometriosis can be challenging. Therapeutic strategies should be tailored to individual symptoms, age and desire for fertility. Endometriosis can be effectively managed with medical therapy, surgery or a combination of both. Therapy is oriented towards the severity of symptoms, the extent of the disease, the location of the disease and the desire for fertility

Medical treatment of endometriosis represents a critical part of the treatment used to attack this debilitating disorder. The main goal of this approach is to eradicate painful symptoms and improve fertility. Reducing the length of endometriotic implants is a secondary goal. Medical therapy clearly represents a less invasive approach than surgical treatment of endometriosis. Most controlled studies evaluate the relative benefits of different medical interventions or a medical intervention compared to placebo

Combined Medical and Surgical Management

The use of medical therapy for the treatment of endometriosis is not limited to independent agents. Doctors have often used drugs in combination with surgery in an attempt to improve results compared to both modalities alone. When this approach is used, medications can be administered before surgery, after surgery, or both. Realizing that surgical technique undoubtedly plays a role in the effectiveness of these approaches, it is still worth examining the available evidence on this rather aggressive attempt to treat endometriosis

There are some retrospective data demonstrating the benefit of medical treatment before surgery for moderate to severe endometriosis. However, there are good data confirming that postoperative medical treatment with gonadotropin releasing hormone agonists for 6 months significantly reduces pelvic pain and delays relapse by more than 12 months. A recent consensus statement by a group of experts concluded that the balance of evidence supports the use of adjuvant postoperative medical therapy after conservative surgery for chronic pelvic pain due to moderate to severe endometriosis