Endometriosis Treatment & Management

endometriosis treatment

Approach Considerations

The dependence of endometriosis on the woman's cyclic production of menstrual cycle hormones provides the basis for medical therapy. Medications currently recommended include gonadotropin-releasing hormone (GnRH) agonists, progestins, oral contraceptive pills, and androgens. Each of these interrupts the normal cyclic production of reproductive hormones. There are some data supporting the use of aromatase inhibitors for refractory or recurrent endometriosis.

Medical vs surgical therapy

In women who wish to preserve their reproductive potential, the rates of recurrent pain symptoms are 44% with surgical management and 53% with medical management. [54, 55]

Endometriosis and subfertility

Peritubal and periovarian adhesions can interfere mechanically with ovum transport and contribute to subfertility. Peritoneal endometriosis has been postulated to contribute to subfertility by interfering with tubal motility, folliculogenesis, and corpus luteum function. Aromatase is believed to increase the prostaglandin E levels via increase in the cyclooxygenase-2 (COX-2) expression. Endometriosis may also cause subfertility by causing more sperm binding to the ampullary epithelium, thereby affecting sperm-endosalpingeal interactions. [56]

Medical treatment of minimal or mild endometriosis has not been shown to increase pregnancy rates. [57] Moderate to severe endometriosis should be treated surgically. [58]

Other options for achieving pregnancy include intrauterine insemination, superovulation, and in vitro fertilization. In a case-controlled study, pregnancy rates with intracytoplasmic sperm injection were not affected by the presence or extent of endometriosis. [59] Furthermore, other analyses have shown improvement with in vitro fertilization pregnancy rates with pretreatment of stage 3 and 4 endometriosis with gonadotropin-releasing hormone (GnRH)

agonists.

Interval treatment

Some authorities believe that endometriosis should be suppressed prophylactically by continuous combined oral contraceptives, GnRH analogs, medroxyprogesterone, or danazol in order to cause regression of asymptomatic disease and enhance subsequent fertility. However, according to a Cochrane review, no benefit is derived from ovulation suppression in subfertile women with endometriosis who wish to conceive. [60]

A Cochrane review of interventions in women with endometriomata (cysts of endometriosis in the ovaries) before the use of assisted reproductive technology (ART) identified 4 trials with 312 participants could reach no conclusions regarding interventions for the management of endometriomata in women undergoing ART. [61]

In a 2015 systematic review and meta-analysis of the influence of endometriosis on ART outcomes from 36 studies (of 1346 articles), investigators found similar outcomes for live births between women with endometriosis who underwent in vitro fertilization and intracytoplasmic sperm injection and women without endometriosis. [62] However, women with severe endometriosis had lower live birth rates, clinical pregnancy rates, and mean number of retrieved oocyte relative to those without endometriosis. The investigators noted there remains not enough evidence to support recommending surgery routinely before women undergo ART. [62]

Surgical ablation of asymptomatic endometriosis has also been shown to improve fecundity rates on a 3-year follow-up. [58]

Recurrent pregnancy loss

Based on results from controlled prospective studies, no evidence indicates that endometriosis is associated with recurrent pregnancy loss, and no evidence indicates that medical or surgical treatment of endometriosis reduces the spontaneous abortion rate. [63]

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