Endometriosis: Conventional Treatment Approaches

Medical treatment of endometriosis includes both pharmaceutical and surgical approaches. Pharmaceutical treatments provide only suppression of the disease; they do not exact a cure. Decisions regarding treatment are based on endometriosis severity and staging, symptom picture, and ultimately, the woman’s needs and goals, for example, desire for children in the future. For women experiencing mild symptoms (or none) and for women who are close to menopause, the appropriate treatment may be to do nothing. For women with mild to moderate symptoms, and those who desire pregnancy, the appropriate pharmacologic therapy should be considered, and if necessary, can be combined with conservative surgery. It should be noted that, in spite of medical treatment, endometriosis has a high recurrence rate of 5% to 20% unless total hysterectomy and bilateral oophorectomy are performed. With pharmacologic interventions, pain typically resumes upon cessation of medications, although initially with pain that is less intense than prior to treatment. Pain relief, pregnancy rates, and recurrence rates are similar with all treatment methods. The goal of pharmaceutical treatment is to interrupt patterns of endometrial stimulation and bleeding. Pharmaceutical options include nonsteroidal anti-inflammatory drugs (NSAIDs) and hormonal therapies (progestins, gonadotropin-releasing hormone analogs, Danazol, and oral contraceptives). NSAIDs (i.e., ibuprofen, naproxen) may be prescribed for mild to moderate pain. They are relatively safe for short-term symptomatic relief; however, long-term use can lead to health consequences, including gastrointestinal bleeding, and should be avoided in patients with a history of peptic ulcer disease or renal failure. It should be noted that none of these therapies demonstrates significant benefit over the others, and all are associated with a high recurrence rate (20%-50%) upon discontinuation of the therapy. Progestins (medroxyprogesterone acetate, i.e., Depo-Provera) suppress the response of endometrial tissue to cyclic hormones, leading to atrophy of this tissue and decreased pain. They are typically better tolerated than oral contraceptives (oral contraceptives), with fewer side effects, and are less costly than Danazol and gonadotropin-releasing hormone analogs. This is often considered the pharmaceutical treatment of choice for endometriosis, although the FDA no longer supports the use of Depo-Provera for this purpose. Side effects include weight gain, fluid retention, and breakthrough bleeding. Depression is a common significant side effect of medroxyprogesterone use. In high doses, medroxyprogesterone can adversely affect lipid profiles, and may lead to a state of hypoestrogenism, with subsequent potential for bone loss. Oral contraceptives are used to control pain in women not desiring pregnancy. The combined effect of estrogen and progesterone is to induce a state of “pseudopreg-nancy,” and appears to lead to a 90% rate of improved symptoms with long-term use. Side effects include all those typically associated with general oral contraceptive use. Danazol, a synthetic testosterone, is used for the treatment of mild to moderate endometriosis in women who desire fertility but not necessarily in the immediate future. It induces a state of “pseudomenopause,” eliminating mid-cycle follicle-stimulating hormone and luteinizing hormone surges. Once considered the optimal treatment for endometriosis, it is now considered no more effective than any of the other pharmaceutical treatments. Possible side effects include weight gain, fluid retention, fatigue, decrease in breast size, hirsutism, atrophic vagi-nitis, hot flashes, muscle cramps, emotional fluctuations, voice changes, spotting, and decreased HDL cholesterol levels. In some patients it may cause hepatocellular damage; thus is contraindicated in patients with liver disease, and liver enzymes should be monitored in all patients during treatment. It is also contraindicated in patients with a history of hypertension, hyperlipidemia, congestive heart failure, renal impairment, and pregnancy. Gonadotropin-releasing hormone analogues (gonadotropin-releasing hormone-a, e.g., Leuprolide) also cause a suppression of endometriosis via a “pseudomenopausal” state. Gonadotropin-releasing hormone treatment does not carry the same risks of negative impact on serum lipids and lipoproteins compared with Danazol; however, it does interfere with calcium metabolism via stimulation of a hypoestrogenic state, and thus can cause osteoporosis. Even after only 6 months of use, a 6% to 8% loss in trabecular bone has been observed. It can take up to 2 years after cessation of treatment to replace this bone loss; thus a treatment is usually restricted to 6-month durations.

Surgical options include conservative surgery (destruction and removal of endometriomas while maintaining reproductive function) and radical surgery (hysterectomy, generally accompanied by bilateral salpingo-oophorectomy). Conservative treatment involves the removal of endometriotic lesions and restoration of normal anatomical relationships via removal of adhesions to the greatest extent possible, with the goal of pain relief, and possible restoration of fertility when achieving pregnancy is desired and has been impaired by the condition. In approximately one-fourth of women treated surgically, however, there is no improvement in fertility even if the disease was considered mild. Procedures include knife excision, laser surgery, electrocautery, curettage, and laparotomy. The worse the disease, the worse the statistics for conceiving after surgery. Recurrence of endometriosis after surgery is dependent on the skill of the surgeon and extent of disease, and as with other endometriosis treatments, rates may be as high as 20%. Hysterectomy will not remove lesions outside the uterus and is not considered a successful treatment when used primarily to reduce the symptom of chronic pelvic pain. Surgery carries the risk of complications, especially adhesion formation and continuing pain. The total rate at which symptoms of chronic pelvic pain returned after drug treatment is estimated to be 5% to 15% at the end of 1 year, or up to 50% at the end of 5 years. Nonetheless, the risks of surgery or medication may be justifiable for severe pain that does not respond to other methods, especially if menopause is not expected for some time. There is a concern that diagnostic microsurgery may aggravate or cause the transfer of viable endometrial cells into general or lymphatic circulation, thereby causing the very condition being identified. Because of this, some wary clients choose natural treatment approaches for the condition without a certain diagnosis, believing that if the signs and symptoms respond, the holistic prescription was correct for the presumed diagnosis.