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Managing endometriosis

It may surprise many but it is certainly true that endometriosis can resolve spontaneously. It is estimated that in up to a third of patients, spontaneous resolution does occur. However, for a majority of people affected by endometriosis, medical intervention is necessary to deal with the condition.

What is important to bear in mind is the fact that, in most cases, the aim of the medical intervention will be to deal effectively with the presenting symptoms in that particular individual rather than aiming for a cure. A cure is rarely achieved unless a radical surgical approach is chosen. I shall discuss this shortly. Many of the medical or surgical solutions offered for endometriosis are very effective achieving the required resolution of symptoms. However, it is common and, in fact, expected that, at some point the symptoms would come back to some degree and further intervention could be necessary.

Hormonal treatment: The use of progestogens on their own or in combination with estrogen is a form of treatment that is often deployed successfully against endometriosis. The use of progestogens will stop the proliferation of endometriotic tissue and put it in a quiescent state. This leads to absence of periods for the duration of the medication. The strategy adopted is usually to take the medication (usually oral tablets) continuously for three months at a time allowing for a week’s break for a withdrawal bleed. The withdrawal bleed tends to be painless.  Since the use of progestogens will also make it unlikely to conceive, this treatment can only be used by somebody who is not actively trying to get pregnant. This treatment can be used for up to 2 years allowing for withdrawal bleeds every 3 months. Alternatively, for such a patient who also wants to have a reliable contraceptive, the injectable contraceptive Depo-Provera can be used instead. The injections are administered every 12 weeks and a user can expect to remain period-free (and symptom-free) during the duration of use.

Another strategy that has been effective for many patients is to use the combined pill continuously without a break for three months at a time. A week’s break is taken after 12 weeks to allow for a withdrawal bleed before resuming the course again. This is ideal for a patient who is symptomatic but who does not desire to conceive and who may, in fact, want to have an effective contraceptive. In the absence of contra-indications (history of thrombosis, a smoker over 35 or clinically obese, active liver disease etc), this treatment can be maintained long term.

Another effective form of hormonal treatment is a group of drugs known as GnRH analogues. All these are given in the form of injections, either every 4 or 12 weeks. These injections work by temporarily shutting down the hormone production from the ovaries. Remember, endometriotic tissue is dependent on estrogen to proliferate and of course progesterone to undergo the changes that lead to its breakdown every month. When the source of these hormones is shut down, endometriosis will shrivel even though it does not disappear completely. The logic of this treatment is, therefore, to mimic menopause, a time when endometriosis resolves permanently. Because of the way this treatment works, there are inevitable side-effects which are similar to the symptoms experienced by women at the onset of menopause. The treatment will also cause some degree of loss of bone mass but this recovers after the treatment. Users will report some degree of hot flushes (flashes), night sweats and in some cases, vaginal dryness.  In some cases these symptoms are so severe that they require medication to relieve them. This is available in the form of tablets known as Tibolone (Livial®) which need to be taken daily. Alternatively, low-dose estrogen skin patches applied once or twice weekly can be used. This is what is known as ‘add-back’ therapy. Either option is usually effective in this regard.  Add-back therapy is actually actively encouraged by many experts in view of its other benefit of preserving bone health during the treatment.

GnRH analogues are a very effective form of treatment when the problem is pelvic pain or painful periods, the commonest feature of endometriosis. Because of the nature of the treatment, it cannot be used by one who is trying to conceive. In fact, it is important to use contraception during the duration of the treatment and that should continue for a minimum of three months after completing the treatment. Treatment with GnRH analogues usually lasts 6 months. Menstrual periods will cease during the treatment and resumption of these is variable. The periods can be expected to resume within 4-8 weeks of completing the treatment but sometimZoladex (Goserelin) for endometriosises it takes a few more months. Many sufferers report remaining symptom-free for many months; even a few years, after completing the treatment. However, this is by no means universal. Some women will report having the symptoms back within a couple of months of resumption of menstruation. Products that fall in this group (GnRH analogues) include Goserelin (Zoladex®), Leuprorelin (Prostap®); Leuprolide (Lupron depot®), all available in the form of injections, usually administered monthly but also available in three monthly injections. There is a GnRH analogue that is administered via a nasal spray and that has to be self-administered twice daily for the same duration (6 months). It is called Nafarelin (Synarel®)

The Levonorgestrel hormone releasing intrauterine device, more popularly known by its brand name Mirena®, has also been used with modest success in cases of endometriosis. About a third of users report significant or complete resolution of painful period. Needless to say, this cannot be used by those trying to conceive.

Surgery: For those women suffering with sub-fertility as a result of endometriosis, medical treatment of any type will not improve their chances of conceiving. If the issue is sub-fertility, the only effective treatment option is surgery.

Surgery for endometriosis is almost always done laparoscopically (‘keyhole’ surgery -image below). It requires the necessary expertise on the part of the surgeon performing the surgery. The extent of the surgery will depend on the extent of the disease in any one individual. Where there are only a few identifiable lesions, these may be excised and/or ablated and that will be sufficient. The other end of the spectrum is where extensive endometriosis has caused considerable distortion in the pelvis, with adhesions, scarring, tissues stuck together and endometriotic (chocolate) cysts in the ovaries. That degree of disease will require much more extensive surgery sometimes lasting several hours.  Where the necessary laparoscopic surgical expertise is unavailable, a traditional open surgery can be performed even though this is clearly second best. Safety is paramount in this and therefore laparoscopic surgery should not be attempted unless the person performing it has the requisite expertise and experience.

Performed properly, surgery for endometriosis significantly improves fertility. In some cases, spontaneous conception will still not occur but it is believed that prior surgery would have, in fact, significantly improved the chances of successful assisted conception (IVF) if this was embarked upon.

Radical surgery to ‘cure’ endometriosis is reserved for severe cases of the disease where there is no plan for future fertility and where the quality of life has been seriously affected by the disease. Such surgery takes the form of a hysterectomy and removal of both ovaries as well as division of adhesions and resection of all the endometriotic lesions that are accessible in the pelvis.

Is surgery feasible?

Many women who have suffered a long period of pelvic pain are tempted to ask their gynaecologist for a ‘hysterectomy’ in the (usually) mistaken belief that this is sure to solve the problem once and for all. It is usually far from that simple. There are many considerations to be taken into account before embarking upon this. A hysterectomy on its own is unlikely to solve the problem because the uterus is not the problem. If this is to be performed, both ovaries need to be removed as well to eliminate the source of the hormones on which endometriosis is dependent. This, of course, sends the woman into instant menopause. The overall effect of this on her general immediate and long term health needs to be taken into account. There is also the issue of the feasibility of the surgery. In some cases of severe endometriosis, the procedure may simply not be possible because of extreme difficulty with access and enormous risk of causing severe harm, even life-threatening, damage to adjacent structures including bowel, major blood vessels, bladder and ureters. No responsible surgeon would want to embark upon a procedure with more chance of causing harm than achieving what is aimed for. It is therefore important for everybody concerned to think carefully before embarking upon this route.

In a nutshell...

Last update: October 08, 2012