In her previous article, Dr Adelene Esterhuizen, gynaecologist at Mediclinic Hermanus, identified the symptoms and diagnosis of endometriosis. She now touches on treatment options. There are several treatment options for endometriosis:
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Hormonal birth control
- Other forms of hormone treatment (gonadotropin-releasing hormone analogs)
- Surgery
Nonsteroidal anti-inflammatory drugs — NSAIDs are a type of pain medicine that can help to relieve the pain caused by endometriosis. They work by stopping the release of prostaglandins, one of the main chemicals responsible for pain in general as well as painful menstrual periods.
“Starting these medications one to two days before your period works best to prevent prostaglandin production and therefore reduce menstrual pain. It may take some time, and several doses, for the NSAIDs to block the prostaglandin production and reduce pain. NSAIDs do not shrink or prevent the growth of endometriosis tissue,” Dr Esterhuizen explains. Most NSAIDs are available without a prescription, like Ibuprofen.
The disadvantage of NSAIDs is that they do not always relieve endometriosis-related pain. NSAIDs probably work better when combined with another treatment, like hormonal birth control. Serious side effects from NSAIDs, although uncommon, include stomach upset and kidney problems.
Hormone therapy
Hormonal birth control methods — Hormonal birth control methods, including oral pills, patches, and vaginal rings, are often helpful in treating pain because they reduce or prevent menstrual bleeding. Daily oral progestin pills as well as injectable and implantable long-acting progestins may be very effective in managing endometriosis-related pain. A progestin-containing intrauterine device (IUD) can also be very effective in treating pain.
The most common side effects of estrogen-containing hormonal birth control are:
- Nausea
- Breast tenderness
- Irregular vaginal bleeding or "spotting" between periods
“These side effects usually improve after using the treatment for several months. Serious side effects (e.g., blood clots, stroke, and heart attack) are rare in people who do not smoke. Not all individuals qualify for the use of systemic hormones – if the risk is too high, your doctor should be able to tell you,” she highlights further.
Progestins — Progestins are a synthetic form of a natural hormone called progesterone. This treatment might be recommended if you do not get pain relief from or cannot take hormonal birth control that contains estrogen (high DVT risk). Progestins require a prescription and are usually given as a pill or injection. They are not used if you are trying to get pregnant. A progestin-containing IUD (e.g. Mirena) delivers very low levels of progestin directly to the uterus and results in markedly lighter and less painful periods.
Side effects of progestins can be bothersome for some people. The most common side effects include bloating, weight gain, irregular vaginal bleeding, acne, and, rarely, worsened depression.
Visanne is a Progestin only agent that was specifically manufactured to combat endometriosis. Some studies suggest that after 3-6 months of continuous use, the results of reduction in endometrial tissue is similar to that of surgical removal. Unfortunately cost and the side effect profile are limiting factors, although a generic has arrived to market.
Gonadotropin-releasing hormone analogs — Gonadotropin-releasing hormone (GnRH) analogs include GnRH "agonists" and GnRH "antagonists." Both types of medication cause the ovaries to temporarily stop producing estrogen. This causes the endometriosis tissue to shrink.
Due to the side effect profile and long-term consequences, this is not something routinely used, and only in the most treatment resistant cases.
Surgery — “As discussed previously, in some cases, surgery is done to diagnose endometriosis (and possibly remove it) before you try treatment with medication. Other times, surgery is considered when medications do not work well enough to relieve pain,” warns Dr Esterhuizen.
A diagnostic laparoscopy is definitely preferred over open surgery, as it is less invasive with better recovery rates. It gets done under general anaethesia. A camera is placed through a port at the belly button. Depending on severity of disease, one or more alternative ports may then be placed over the lower abdomen to gain access to the abdomen and pelvis, and excise abnormal tissue. Reconstruction may also be necessary, and it is worth mentioning that not any gynaecologist may operate on any patient. Some gynaecologists have done advanced laparoscopic training, and some others are “all-rounders”, who may operate on stage 1 disease (although this might be quite hard to determine on clinical examination alone). It is essential that the surgeon has undergone adequate training in laparoscopic surgery.
Different methods may be used to remove or destroy endometriosis tissue during surgery.
The goal of surgery is to remove endometriosis and scar tissue. Approximately 75% of people who have this surgery have less pain for several months after surgery. However, surgery is not a permanent cure, and there is a good chance that the endometriosis tissue will eventually grow back and your pain will return unless you take some form of treatment after surgery, such as hormonal birth control.
In some cases, rather than just removing or destroying endometriosis tissue, the entire uterus (and sometimes the ovaries) is removed. This is typically reserved for people who continue to have severe symptoms despite other treatments and who do not wish to become pregnant in the future.
Infertility treatment
There are several options for treating infertility related to endometriosis. The best treatment depends on individual factors, including your age, whether you have other fertility issues, and how severe your endometriosis is. Treatment options include:
- Medication to cause ovulation, such as clomiphene, or letrozole.
- Fertility medicines plus intrauterine insemination (IUI).
- Surgery to remove endometriosis tissue.
- In vitro fertilization (IVF).
Conclusion
Dr Esterhuizen closes, “Endometriosis is a poorly understood, chronic and potentially debilitating condition. It affects up to 1 in 10 women of reproductive years, and likely even more, seeing as some women get misdiagnosed, and some are asymptomatic. It is important not to ignore symptoms and rather speak to a specialist to make the diagnosis timeously. Although it cannot be cured, it can be managed in order to make symptoms bearable, to avoid fertility issues and long term sequelae, like chronic pelvic pain.”
