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Indications for Medical treatment of endometriosis

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Mistakes

  • Medical treatment without a diagnostic laparoscopy should never been done since the diagnosis is not made.
  • Medical therapy because surgery has been incomplete because of a lack of experience
  • Medical treatment before surgery should rarely be done since smaller lesions risk to be missed.

Useless

  • Medical therapy for infertility and endometriosis

Indications

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  • Medical therapy after surgery when surgery was too delicate to be complete
  • Medical treatment to prevent recurrences Although few solid data exist we believe that oral contraception might reduce recurrences of typical endometriosis
  • Medical treatment to prevent progression : no data.

Side effects

  • Orgametril induced weight gain,
  • GNRH induced osteoporosis

Results and safety of medical therapy

  • This therapy is based upon the knowledge that endometriosis is an hormone responsive tissue : in the absence of oestrogens endometriosis is less active and in the presence of progesterone endometriosis decidualises.
  • Medical therapy is generally effective in decreasing pain, but not always
  • Medical therapy is considered safe but
    • some deep endometriosis lesions can have severe complications during pregnancy such as bowel obstructions, and bowel or bladder perforations
    • it is likely that during medical therapy endometriosis progresses in some women at least, making surgery more difficult

 

Types of Medical Therapy for endometriosis

Medical menopause : LHRH agonists (or antagonists)


LHRH agonists (eg Lupron Depot, Synarel, Zoladex, Decapeptyl) will suppress ovarian function, resulting in an artificial menopause with all its consequences such as hot flushes, night sweats, insomnia, vaginal dryness, loss of sexual interest, and depression.
According to the FDA LHRH agonists should not be taken for longer than six months in a lifetime because of the risk of osteoporosis.
Can give excellent pain relief but the symptoms will come back after treatment has been stopped.
Can be associated with add back therapy (small doses of estrogens) enough to prevent the worst menopause symptoms

Progestagens only and oral contraception

Higher doses of progestagens (eg orgametril, lutenyl, danazol) decidualise and growth of the endometrium and endometriosis as occurs during pregnancy
Can give pain relief but the symptoms will come back after treatment has been stopped.
Higher doses of these progestagens with some androgenic side effects, invariably are associated with weight gain and symptoms of androgenisation
Oral contraception probably remains the best choice. When given continuously, the recurrence of cystic ovarian endometriosis is less

Experimental drugs

Anti-progestins primate experiments suggest they might be as effective as GNRH agonist without the side effects. Today no drugs are approved for endometriosis.
Aromatase inhibitors : since endometriosis lesions produce estrogens within the lesions it might be useful to suppress this activity. Today there is no evidence of clinical superiority.
Anti-angiogenic products. Since endometriosis is associated with local angiogenesis, something we demonstrated back in 1994, this might be a logic approach in the future.
Anti TNFa drugs This therapy has been hyped following preliminary evidence of decreasing implantation in primates. It is a typical example how research data were overemphasized by their authors. We recently demonstrated that in women anti TNFa is not effective for pain.

nawareness of the important placebo effect for any type of medical therapy , as demonstrated for TNFa . In this article we asked the question whether medical therapy indeed does reduce pain. We wrote in the discussion “We have scrutinized the literature on the medical treatment of endometriosis associated pain. The evidence of efficacy maybe weak as the blinding in most studies appears inadequate.Researchers and patients were able to guess whether individuals were randomized to placebo or active treatment if menstruation was prevented or if there were major side-effects such as hot flushes, or recognizable physical signs such as vaginal atrophy. In addition, conclusions are usually based abolish menstruation will thus by definition be effective in reducing dysmenorrhea. Given the strong correlation between pain symptoms it remains uncertain whether these treatments are effective for all pain symptoms associated with endometriosis or simply dysmenorrhea alone.”

 

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