Treatment of Endometriosis
Written by Dr.M.D.Mazumdar, MD
There are two main aims of treatment of endometriosis - the first aim is to stimulate healing of the abnormal endometriotic tissue and the second aim is to remove or decrease adhesion between the different pelvic organs.
Types of Treatment of Endometriosis
The treatment of endometriosis depends on the stage of the disease. In early stages, when the patient has mild symptoms, and scarring and adhesions inside the pelvis is minimal or absent, hormones are the main form of treatment. In later stages, surgery becomes essential.
Hormonal treatment of endometriosis was first started when it was noticed that the disease healed spontaneously during pregnancy and after the menopause. During these periods, menstrual periods do not occur since there is no growth of the endometrium (inner lining of the uterus). Growth and bleeding from the abnormal endometriotic tissue also stopped at the same time leading to healing of the endometriotic tissues.
The idea behind the various hormonal treatment protocols is to cause a psuedo-pregnancy state and stop bleeding from the abnormal tissue. This causes atrophy of the endometrial tissue outside the uterus.
The hormones prescribed stops proliferation of the endometrium inside the uterus as well as the endometriotic tissue outside it as long as they are taken regularly. Lack of stimulation causes atrophy of the endometriotic tissue.
Androgens are male hormones which have a direct depressing action on the endometrial tissue. Since the androgens are anti-oestrogenic and stops menstruation, the patient may have menopausal symptoms like hot flushes and weight gain. Stimulation by androgens can also cause slight growth of hair on the face, acne and deepening of the voice.
These effects go away once the drug is stopped. The patient should always be told about these effects before starting these medicines. The newer synthetic androgens like Danazol however have much less side-effects.
- Danazol: Danazol is the drug of choice for the treatment of endometriosis. It is a synthetic derivative of ethisterone with minimal androgenic activity. Dosage ranges from 200mg to 800 mg daily depending on the extent of the disease.
The patient usually gets relief within 4 weeks. USG is repeated after 3 months, 6 months and 9 months to check for the response of the patient. Most endometriotic tissue atrophy completely in 9 months. The main disadvantage is that the medicine is costly.
- Methyltestosterone in the dose of 5 mg daily were prescribed earlier but is obsolete nowadays since the discovery of danazol.
Progesterones are female hormones used in high doses for management of endometriosis.
- High dose Progesterone: High dose progesterone can be given continuously for 9 - 12 months to cause complete cessation of menstruation. This will also cause the abnormal endometriotic tissue to become inactive and die off.
- Dydrogesterone: Dydrogesterone is a type of progesterone which, like all progesterones, causes secretory changes in the endometriotic nodules and prevent their proliferation. This causes the nodules to atrophy. It is given daily for three months.
The advantage of this medicine is that, unlike danazol, it does not stop ovulation and pregnancy can occur during the course of treatment. Another progesterone used is the medroxy progesterone.
Oestrogen-Progesterone: combined therapy can be given to cause a false pregnancy state and stop proliferation of the tissues.
LHRH Agonists: These prevent follicular maturation and ovulation and produce a follicular deprivation state leading to atrophy of the endometriosis. They are available as nasal spray and injections (e.g. Lupron). Disadvantage is their high cost.
Surgery is indicated in cases with huge cysts and where the lesions are deep seated.
- Laparoscopy: At laparoscopy, it is possible to burn off the endometriotic nodules and remove any ovarian cysts. Adhesions can also be removed. It is the best option where the the patient is young and and would like to keep her fertility.
- Hysterectomy: Hysterectomy or removal of the uterus is best where the disease is so far progressed that the uterus and other affected tissues need to be removed. The ovaries may be preserved or removed as deemed fit.
Some doctors advocate a 'wait and watch' approach when the woman is nearing menopause and it is expected that the disease will subside naturally once menopause occurs.
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