gynecology and obstetrics
Endometriosis
Treatment of Endometriosis
Nonsteroidal anti-inflammatory drugs (NSAIDs) for discomfort Estrogen-progestin contraceptives Drugs to suppress ovarian function Conservative surgical resection or ablation of endometriotic tissue, with or without drugs Total abdominal hysterectomy with or without bilateral salpingo-oophorectomy if disease is severe and the patient has completed childbearing Symptomatic medical treatment begins with analgesics (usually NSAIDs) and hormonal contraceptives. Drugs and conservative surgery are used mainly to control symptoms. In most patients, endometriosis recurs within 6 months to 1 year after drugs are stopped unless ovarian function is permanently and completely ablated. Endometriosis may also recur after conservative surgery. Conservative surgical treatment of endometriosis is excision or ablation of endometriotic implants and removal of pelvic adhesions during laparoscopy. More definitive treatment must be individualized based on the patient's age, symptoms, and desire to preserve fertility and on the extent of the disorder. Total abdominal hysterectomy with or without bilateral salpingo-oophorectomy is considered definitive treatment of endometriosis. It helps prevent complications and modify the course of disease as well as relieving symptoms; however, endometriosis can recur. Drugs that suppress ovarian function inhibit the growth and activity of endometriotic implants. The following are commonly used: Continuous combination (estrogen-progestin) Oral Contraceptives None The following drugs are usually used only when women cannot take combination oral contraceptives or when treatment with combination oral contraceptives is ineffective: Progestins Gonadotropin-releasing hormone (GnRH) agonists and antagonists Danazol GnRH agonistsinitially increase hypothalamic GnRH secretion, but continued use then temporarily decreases pituitary release of follicle-stimulating hormone (FSH), resulting in a decreased inestrogenproduction by the ovaries; however, treatment is limited to≤6 months because long-term use may result in bone loss. If treatment lasts>4 to 6 months, a progestin or a bisphosphonate may be used concurrently to minimize bone loss. If endometriosis recurs, women may need to be treated again. TheGnRH antagonistelagolixdirectly decreases GnRH secretion and thus suppresses pituitary release of FSH andestrogenproduction by the ovaries. It is available in 2 different doses; the higher dose is available to treat dyspareunia as well as other symptoms of endometriosis. Long-term use may result in bone loss. If treatment lasts > 6 months, a progestin may be used concurrently (as add-back therapy) to minimize bone loss. The GnRH antagonistrelugolixcombined withestradiol1 mg andnorethindrone0.5 mg is undergoing clinical trials for use as primary treatment for endometriosis; this combination minimizes hot flushes and bone loss; use is limited to 24 months because possible continued bone loss may be irreversible. Danazol, a synthetic androgen and an antigonadotropin, inhibits ovulation. However, its androgenic adverse effects limit its use. Cyclic or continuouscombination oral contraceptivesgiven afterdanazolor GnRH agonists may slow disease progression and are warranted for women who wish to delay childbearing. Drug treatment does not change fertility rates in women with minimal or mild endometriosis. Most women with moderate to severe endometriosis are treated most effectively by ablating or excising as many implants as possible while restoring pelvic anatomy and preserving fertility as much as possible. Superficial endometriotic implants can be ablated. Deep, extensive implants should be excised. Specific indications for laparoscopic surgery include Moderate to severe pelvic pain that does not respond to drugs Presence of endometriomas Significant pelvic adhesions Fallopian tube obstruction A desire to maintain fertility Pain during intercourse Lesions are usually removed via a laparoscope; peritoneal or ovarian lesions can sometimes be electrocauterized, excised, or, uncommonly, vaporized with a laser. Endometriomas should be removed because removal prevents recurrence more effectively than drainage. After this treatment, fertility rates are inversely proportional to the severity of endometriosis. If resection is incomplete, GnRH agonists are sometimes given during the perioperative period, but whether this tactic increases fertility rates is unclear. Laparoscopic resection of the uterosacral ligaments with electrocautery or a laser may reduce midline pelvic pain. Rectovaginal endometriosis, the most severe form of the disease, can be treated with the usual treatments for endometriosis; however, colon resection or surgery may be required to prevent obstruction of the colon. Hysterectomywith or without ovarian conservation should usually be reserved for patients who have moderate to severe pelvic pain, who have completed childbearing, and who prefer a definitive procedure. Hysterectomy is done to remove adhesions or implants that adhere to the uterus or cul-de-sac. If women < 50 require hysterectomy with bilateral salpingo-oophorectomy, supplemental estrogen should be considered (eg, to prevent menopausal symptoms). Also, concomitant continuous progestin therapy (eg,medroxyprogesteroneacetate 2.5 mg orally once a day) is often recommended because if estrogen is given alone, residual tissue may grow, resulting in recurrence. If symptoms persist after salpingo-oophorectomy in women > 50, continuous progestin therapy alone (norethindroneacetate 2.5 to 5 mg,medroxyprogesteroneacetate 5 mg orally once a day, micronizedprogesterone100 to 200 mg orally at bedtime) can be tried. 