Medical Treatment For Endometriosis
Majority of women diagnosed with Endometriosis (i.e. 70%) are symptomatic,and pelvic pain is the primary complaint. Women may also suffer from painful period, painful intercourse, painful defecation, irregular menstrual bleeding, low back pain, blood in the urine and pain urination. Pain in endometriosis is caused by increase inflammatory mediators, neurological dysfunction, and estrogen mediated neuro-modulation of the peripheral nerve sensory neurons. As a painful syndrome, Endometriosis severely reduce the quality of life, and damage the mental and emotional health. In most cases, medical treatment is first line treatment, usually commenced base on presumptive diagnosis on clinical assessment. The aims are to modify the hormonal miliue of the body and the suppress the inflammatory mediators.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
NSAIDs work by blocking the enzyme COX (which help to produce inflammatory mediators). Besides controlling pain, NSAIDs recently have been shown to inhibit endometrial tissue growth.
Birth Control Pills (Combined Oral Contraceptives)
The combined hormones decidualizes the endometriotic tissues, therefore slowing down disease progression.
These suppresses estrogen release indirectly, achieving regression of the endometriotic tissues. It is approved only to be use for up to 6 months because of significant side effects (bone loss, vaginal dryness, hot flashes and abnormal lipid profiles.
These are used similarly to GnRH Agonists. The advantages are less side effects and equivalent pain improvement.
Progesterone Containing Contraceptives
Progesterone act to interfere with several mechanisms that induce endometriosis. Over the years, many formulae have been developed.
Medroxyprogesterone injection every 3 monthly
Dienogest(Vissanne) daily: less anti-androgenic effect, well tolerated with irregular bleeding that improves with time.
Mirena IUS: boasts of better side effect profle. Effective by inducing endometrial atrophy, reduced retrograde menstruation and higher peritoneal perfusion with better local effect.
Etonogestrel IMPLANON implant: inserted subdermally, lasting for 3 years. Side effects are similar to medroxyprogesterone (i.e. irregular menstrual bleeding, weight gain, nausea, headache, breast tenderness and acne).
Selective Progesterone Receptor Modulators (SPRMs)
New agents: Mifepristone and Ulipristal. Mechanisms are inhibit endometrial growth, reduced endometrial blood supply and thus reduced menstrual bleeding. Without side effect of reduced estrogen.
They block estrogen synthesis both in the periphery and the ovaries. Very helpful in postmenopausal women with endometriosis. May also be combined with the other agents to have better outcome. Their side effects are ovarian follicular cyst formation and bone loss.
Androgenic agent that inhibit ovarian estrogen formation. Effective but side effects significant, so less used.
Experimental agents, aim to reduce blood supply to enodometrotic lesions and shrink them (e.g. TNP-470, Endostatin, Anginex, anti-VEGF antibody (Avastin), Cabergoline and quinagolide.
They hae anti-inflammatory, anti-angiogenic and anti-oxidant properties. Potential benefits in endometriosis.
TNF-alpha is a pro-inflammatory cytokine associated with genesis of endometrosis. Effective blocking of it may help to control the disease. Still experimental.
The number of pharma agents for the management of endometiosis is increasing. Medical treatment is extremely important in the group of young women who have not completed their family. Controlling the endometriosis process not only reduces the suffering but also improve he chance of child-bearing.