Medical Treatment for Endometriosis
Historical Medical Approaches
Multiple studies have reported a 4-5 times improvement in fecundity (monthly chance of conception) with empirical treatment, superovulation with either clomiphene or injectable gonadotropins combined with intrauterine insemination.
A number of different types of medical regimens have been tried but discarded because of adverse side effects and questionable results: androgen, estrogen, progestin, and high-dose estrogen-progestin. The aim of all these therapies was to suppress ovulation and menses for a prolonged period of time in hopes that in an unstimulated environment (decidualization) the disease would regress.
Birth Control Pills, Danazol, Lupron, Synarel, Zoladex, depot-Provera and Norplant have not been proven effective as either primary or adjunctive therapy (combined with surgery) for endometriosis related infertility. While the use of medical treatment may decrease inflammatory reactions making surgical correction easier and reduce endometriosis-related pain, use of these medications in patients with minimal disease is of no proven benefit in treating infertility.
"Taking the Pill Decreases Pain but Won't Help You Get Pregnant"
Because many women reported that their symptoms from endometriosis subsided when they were on birth control pills, doctors began using the Pill to control the disease. By suppressing their periods for nine months or more with very high-dose birth control pills, 80 to 90 percent of these women suffered less pain, and nearly half became pregnant when they discontinued the medication. However, endometriosis recurred in a third of these patients. Because of the adverse side effects from high-dose hormones and the marginal results, high-dose birth control pills are not used today to treat endometriosis.
Today's low-dose birth control pill not only may reduce the risk of developing endometriosis, but for many it also seems to provide temporary relief from the symptoms. Some physicians suggest that their patients skip the placebo pills (pills 22-28) and start a new pack each 21 days. While this may be an effective method of treating pain related to endometriosis, the Pill is also very effective contraceptive.
The Pill may also preserve the woman's fertility by temporarily containing the milder forms of the disease. For these reasons young women with endometriosis may wish to take the Pill until they decide to start their families. Another option is the LNG-containing IUS [Mirena].
I should caution you, however, that if you suspect you have endometriosis, you should not delay treatment by taking birth control pills until you are thirty years old. By then the disease may already silently have invaded your reproductive organs and made restoring your fertility difficult.
GnRH agonists Can Provide Relief
The pituitary hormone LH and FSH stimulate ovarian production of estrogen, the major stimulus for growth of endometriosis. By blocking the production and release of LH and FSH, GnRH agonist (Lupron, Synarel, Zoladex and GonaPeptyl) lower estrogen to menopausal levels. The drug creates the pseudomenopausal state desirable for reducing the size and number of endometriotic lesions. Synarel, a daily nasal spray; Lupronand GonaPeptyl, a monthly injection; and Zoladex, a monthly implant; appear to be equally effective.
Side effects are most often due to the lowered estrogen levels. They include: hot flashes, vaginal dryness, headaches and sleep disturbances. Rarely, complications such as short term memory loss, muscle, bone and joint pains and decreased bone calcium. Soreness at the injection site may be seen with Lupron and Zoladex, while nasal stuffiness and burning have been reported with the use of Synarel.
These medications are approved for six months of use, and many endometriosis sufferers report six months of blissful relief. Unfortunately, not all women respond and GnRH agonists are definitely not a cure for endometriosis. They merely suppress endometriosis during the course of therapy. Unfortunately, without aggressive surgical excision, endometriosis often returns within months of discontinuing any of these medications. So why use them if the endometriosis is going to return?
- GnRH agonists reduce endometriosis-related pain.
- GnRH agonists may facilitate surgical treatment.
- GnRH agonists can be used as a diagnostic tool.
- GnRH agonists do not restore normal fertility in patients with endometriosis.
Medical Therapy Combined with Surgery
In women with more severe endometriosis (stage III or IV), medical therapy may be combined with surgery to provide even better results. Frequently physicians prescribe the medication prior to surgery to reduce the number and size of the lesions. Surgery following medical treatment is much less likely to destroy healthy tissue and cause adhesions.
To reduce inflammation and in an attempt to clear up any remaining endometriosis, medical treatment is also prescribed following surgery. Reportedly this approach increases the chances for women with severe endometriosis to become pregnant. Some physicians, however, feel that since the highest levels of fertility immediately follow surgery, postponing ovulation with postsurgical medical treatment may rob you of your best chances for pregnancy.
Therapy for Mild Endometriosis (Stages I and II)
Treatments for mild forms of the disease are controversial. Some physicians feel that since adhesions may not form at this stage,it's better to take a wait-and-see approach (expectant therapy)rather than prescribing heavy doses of medication. Although most studies have found no proven benefit of surgical treatment for minimal endometriosis, more recent studies suggest increased pregnancy rates after completely excising all endometriosis. Therefore, as endometriosis progresses in up to 60% of women if untreated, aggressive surgical management at the time of discovery leads to the long term best results.
After excising all endometrial implants with the laparoscope, up to 75 percent of these women will become pregnant within twelve to eighteen months without additional medication. If no pregnancy occurs within six, the patient is older than 35 years of age or, has been attempting pregnancy for over two years, superovulation and intrauterine insemination is often successful.
For those with extensive inflammatory endometriosis, I recommend a short course of GnRH agonist followed immediately by more agressive therapy. However, for most patients with minimal or mild disease who have undergone complete surgical excision, the use of GnRH agonists are not likely to improve pregnancy rates or prevent recurrences.
Therapy for Moderate and Severe Endometriosis (Stages III and IV)
Stages III and IV endometriosis, however, often cause thicker and broader-based adhesions than early endometriosis and often cause the ovary to stick to the pelvic sidewall. Frequently the wall of the large bowel or rectum are involved and a portion of the bowel will also need to be removed. Since the removal of these types of adhesions and endometriosis of the bowel and rectum require more care than removing the filmy ones associated with earlier stages of the disease, this type of surgery is best performed by a well skilled endometriosis team.
Prior to planning your surgery, we may recommend a barium enema (x-ray) or an office procedure where the rectum and sigmoid colon are visualized with a flexible telescope. To safely perform bowel surgery it is sometimes necessary to perform a bowel prep a day or two before surgery (enemas, antibiotics and KleenPrep).
Resolving Multiple Problems Is a Complex Task
Because endometriosis may cause so many fertility problems - anovulation, luteal phase defect, adhesions, tubal blockage, ectopic pregnancies, and idiopathic (unknown) infertility - treating endometriosis can be very complex. I may have to decide if ovulation induction will work in the presence of the disease; or if the endometriosis must be treated before trying ovulation induction therapy. And before even attempting ovulation induction therapy, I must be relatively certain that adhesions will not interfere with fertilization or cause an ectopic pregnancy. If you are at risk for an ectopic pregnancy, medical and endoscopic surgical treatment may significantly reduce your risks for this complication.
After surgery to remove endometrial implants, clear adhesions, and perform tubal repairs, we must reassess your fertility potential. Together we can explore the post surgical treatment options below and develop a plan that best meets your needs.
- Expectant management (wait & see)
- Ovulation induction and intrauterine insemination
- In vitro fertilization
Fortunately there are many ways to solve these problems and get all of your systems working in perfect harmony so you will have your chance at making a baby - the greatest miracle of all.
