Question 35. Are there medical treatments for endometriosis?

Occasionally I am asked to see a patient with endometriosis who is not interested in fertility. Although I can certainly manage these patients, I honestly think that they are better served by going to a non-fertility clinic RE. Our practice is pretty much 100% geared to the needs of fertility patients and I wonder if those patients who are not seeking pregnancy ultimately feel like a fish out of water in our waiting room....

Fortunately there are some effective medical treatments for endometriosis. Unfortunately, all of these treatments shut down reproduction so they are not appropriate for the endometriosis patient seeking pregnancy.

Meanwhile I wanted to share the exciting news that the 2nd Edition of 100 Questions and Answers about Infertility is at the printers! Let the presses roll!

35. Are there medical treatments for endometriosis?

Several medications are used to treat endometriosis. All of these medications suppress ovulation and cause a hypoestrogenic state. Understandably, suppressing ovulation also prevents pregnancy from occurring so medical therapy is not appropriate in patients actively seeking fertility. In patients who are not trying to conceive, medical treatment of endometriosis can be very beneficial and relieve symptoms of dysmenorrhea and pelvic pain.

One common medical treatment is to prescribe the combination oral contraceptive pill. Although each of these daily pills contains estrogen, the progestin (progesterone-like component) in the pill overrides the estrogen effect, resulting in suppression of endometriotic lesions. Oral contraceptive pills are effective in 30% to 60% of patients with endometriosis-related pain.

Many physicians prescribe gonadotropin-releasing hormone (GnRH) analogs (such as Lupron), which reduce estrogen levels to postmenopausal levels for their patients with endometriosis. These medications suppress estrogen production, prevent ovulation, and cause atrophy of the endometriosis in 70% to 90% patients. Unfortunately, GnRH analogs are expensive and must be given as injections either once a month or every 3 months. GnRH agonists can cause side effects including headaches, hot flashes, moodiness, insomnia, and vaginal dryness. To counteract these side effects experienced by many patients treated with GnRH agonists, physicians often prescribe oral contraceptive pills or supplemental progestin therapy (such as norethindrone) along with the GnRH analogs. This combined therapy ay allow for improved treatment acceptance through the alleviation of the many side effects associated with the use of the GnRH analogs as single therapy. Patients tolerate this combination very well and achieve maximal benefits in suppressing the disease and its symptoms.

As noted previously, medical therapy is not indicated for patients with endometriosis who are actively trying to conceive, since all of these treatments will suppress ovulation. Instead, for these patients, the goal should be to promptly establish pregnancy before the endometriosis causes any further damage to the reproductive organs. Generally, these women should seek treatment from a fertility expert to maximize their chances for successful pregnancy.