TREATMENT
Available therapies include
expectant, hormonal, surgical, and combination medical-and-surgical treatment.
The choice of treatment depends on the patient’s individual
No treatment
provides a permanent cure. Total abdominal hys-terectomy with bilateral
salpingo-oophorectomy is associ-ated with a 10% risk of recurrent symptoms and
a 4% risk of additional endometriosis. Reasonable goals for manage-ment of
endometriosis include reduction in pelvic pain, minimizing surgical
intervention, and preserving fertility.
Patients can be treated
expectantly (i.e., without either medical or surgical therapy) in some selected
cases, includ-ing patients with limited disease whose symptoms are minimal or
nonexistent or patients who are attempting to conceive. Because endometriosis
responds to estrogen and progesterone, older patients with mild symptoms may
opt to wait until the natural decrease in levels of these hor-mones that occurs
with menopause.
Because the glands and stroma of
endometriosis respond to both exogenous and endogenous hormones, suppression of
endometriosis is based on a medication’s potential abil-ity to induce atrophy
of the endometrial tissue. This treat-ment approach is optimal for patients who
are currently symptomatic, have documented endometriosis beyond minimal
disease, or who desire pregnancy in the future. The patient should be aware
that recurrence after the com-pletion of medical therapy is common and that
medical therapy does not affect adhesions and fibrosis caused by the
endometriosis. Medical therapy may often be instituted empirically without a
definitive surgical diagnosis of endo-metriosis, if the patient’s symptoms are
consistent with the disease and appropriate, thorough physical examination and
workup have been performed to rule out other causes of pain, including
gynecological, gastrointestinal, and uro-logic causes.
Because of their ease of
administration and relatively low level of side effects, combined oral
contraceptives used in conjunction with NSAIDs are often the first line of
treatment for pain associated with endometriosis. Oral con-traceptive therapy induces a decidual reaction in the
functioning endometriotic tissue. Continuous therapy, in which the
oralcontraceptive regimen is taken continuously without the 7 days of inactive
pills that induce withdrawal bleeding, can also be prescribed to prevent
secondary dysmenorrhea.
Progesterone
therapy, in the form of injectable depome-droxyprogesterone acetate (DMPA) or
implants, suppresses gonadotropin release and, in turn, ovarian
steroidogenesis; it also directly affects the uterine endometrium and
endometrial implants. DMPA has been associated with an
increased riskof bone mineral loss and its use should be weighed againsta
woman’s existing risk factors for osteoporosis.
Danazol is a medication that
suppresses both luteiniz-ing hormone (LH) and follicle-stimulating hormone
(FSH) midcycle surges. In the absence of LH and FSH stimula-tion, the ovary no
longer produces estrogen, which induces amenorrhea and endometrial atrophy.
Side effects of dana-zol, which occur in a minority of patients, are related to
its hypoestrogenic and androgenic properties and include acne, spotting and
bleeding, hot flushes, oily skin, growth of facial hair, decreased libido, and
atrophic vaginitis, and deepening of the voice. Some of these side effects do
not resolve with the discontinuation of therapy. Lipoprotein metabolism is also
altered; serum high-density lipoprotein (HDL) levels increase significantly while
low-density lipo-protein (LDL) levels decrease.
Comparable symptom relief can be
achieved with fewer effects using gonadotropin-releasing hormone (GnRH)
agonists. GnRH agonists down-regulate the
pituitary gland andcause marked suppression of LH and FSH. However, the
sideeffects are less severe than those of danazol, because andro-genic side
effects are eliminated. However, the hypoestro-genic effect produced by GnRH
agonists may cause hot flushes and night sweats and a slight increase in the
risk of bone density loss. If a patient develops side effects while tak-ing a
GnRH agonist, if the therapy is required for longer than 6 months, or if
repeated treatments are required, add-back
therapy consisting of low-dose combination oralcontraceptives or medroxyprogesterone
should be consid-ered. Add-back therapy is often started with GnRH agonist
therapy, because it does not affect the drug’s control of pelvic pain and
mitigates the vasomotor and bone density side effects.
The
surgical management of endometriosis can be classified as either conservative
or extirpative. Conservative surgeryincludes excision,
cauterization, or ablation (by laser or electrocoagulation) of visible
endometriotic lesions and preservation of the uterus and other reproductive
organs to allow for a possible future pregnancy. Conservative surgery is often
undertaken at the time of the initial laparoscopy performed for pain or
infertility. If extensive disease is found, conservative surgery involves lysis
of adhesions, removal of active endometriotic lesions, and possibly
reconstruction of reproductive organs. Success rates of conservative surgery
appear to correlate with the severity of the disease at the time of surgery as
well as with the skill of the surgeon. Medical therapy can be instituted before
surgery to reduce the amount of endometriosis, and after surgery to facilitate
healing and prevent recur-rence. Pregnancy rates following electrical energy or
argon laser range from 34% to 75%. Pregnancy rates after car-bon dioxide laser
vaporization range from 25% to 100% for stage 2 disease, from 19% to 66% for
stage 3 disease, and from 25% to 50% for stage 4 disease.
Extirpative
surgery for endometriosis is reserved only for cases in which the disease is so
extensive that conservative med-ical or surgical therapy is not feasible, or
when the patient has completed her family and wishes definitive therapy. Definitivesurgery
includes total abdominal hysterectomy, bilateral salpingo-oophorectomy, lysis
of adhesions, and removal of endometriotic implants. One or both ovaries may be
spared if they are uninvolved and the endometriosis can be resected completely.
Approximately one-third of women treated conservatively will have recurrent
endometriosis and require additional surgery within 5 years. Ovarian
con-servation at the time of hysterectomy carries an increased risk of
recurrent endometriosis requiring additional sur-gery. After bilateral
oophorectomy, estrogen therapy may be initiated immediately, with little risk
of reactivating residual disease.
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