Endometriosis

Introduction

Endometriosis is a common gynaecologic condition that affects females during their reproductive years, defined as the growth of endometrial tissue outside the uterus.

  • Clinically, endometriosis can cause several symptoms with the most common being dysmenorrhea, chronic pelvic pain, dyspareunia and infertility.
  • However, a patient can remain asymptomatic.



Management

Medical management of endometriosis-related pain is non-specific and aimed at alleviating symptoms.

First-line treatment options include

  • Paracetamol or NSAIDs
    • A 3-month trial with or without hormonal therapies is recommended.
  • Continuous administration of combined hormonal contraceptives or progestin alone (e.g. dienogest, norethisterone and medroxyprogesterone).
    • Oral progestogens are indicated if there is a contraindication to oestrogens and long-acting progestogens.
    • Patient acceptability of oral progestogens is poor due to the adverse effects such as breast tenderness, irregular bleeding and headaches. The usual length of treatment is 3 to 6 months, but longer or repeat courses are common. Their long-term use is limited by the risk of hypoestrogenism (affecting bone and possibly cardiovascular health).

For women with endometriosis-related pain refractory to initial treatment with oral contraceptives and NSAIDs, consider

  • Empiric treatment with a 3-month course of GnRH agonist (e.g. leuprolide IM injection, triptorelin IM injection, goserelin implant, nafarelin nasal spray) with hormone therapy
    • GnRH agonists may cause hypoestrogenic adverse effects (e.g. hot flushes, vaginal dryness, decreased bone mineral density), which limit their duration of use to 6 months.
    • Oestrogen and progestogen replacement (with doses typically used for combined menopausal hormone therapy) reduce these adverse effects, allowing GnRH agonist use for up to 2 years.
    • Use GnRH agonists with caution in young people, particularly adolescents, because GnRH agonists may limit peak bone mass.
  • Levonorgestrel-releasing intrauterine device (IUD)
  • Danazol
    • Is reserved for use by specialists when other treatments are not tolerated.
    • It has significant adverse effects (e.g. hirsutism, acne, voice change, liver toxicity, dyslipidaemia, a small increase in the risk of ovarian cancer), and treatment duration is limited to 6 to 9 months.
    • An effective nonhormonal method of contraception must be used concurrently during treatment with danazol.
  • Aromatase inhibitors, e.g. letrozole, anastrozole - Off-label use

Surgical management of endometriosis is indicated for treatment of severe pain or infertility.

  • It involves laparoscopic removal or destruction of endometriotic tissue, or hysterectomy.



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