Endometriosis management David Jung

1. Overview
a. Medical therapy (Analgesics and hormonal ovarian suppression) is effective for treating pain
b. Surgical treatment (Laparoscopy) is considered after 3-6 months of no symptom relief
c. Endometriosis is difficult to treat due to
i. physical pain and associated psychological issues
ii. recurrence throughout reproductive life
d. Coexisting diseases (up to 80%)
i. IBS
ii. Constipation
e. Medical therapy
i. Analgesics
ii. Combined oral contraceptives
iii. Progestogens
iv. Gonadotrophin releasing hormone agonist
v. Other hormonal agents: aromatase inhibitors
f. Surgical treatment
i. Fertility sparing surgery
ii. Hysterectomy and oophorectomy
2. Medical therapy
3. Analgesics
a. NSAIDs
i. Used for dysmenorrhea and pelvic pain i.e. symptomatic control only
b. Avoid Codeine/Opiates
i. Worsens IBS
4. Combined oral contraceptives (COCP)
a. COCP is used for
i. Dyspareunia
ii. Dysmenorrhea
iii. Non menstrual pain
b. How to take COCP for endometriosis
i. Sequentially with 7 day pill free break
ii. Tricycle (3 packets back to back)*
iii. Continuously without break *
1. *more effective on cyclical dysmenorrhea by inducing amenorrhea
c. Symptomatic relief with treatment: continue until pregnancy desired
d. Symptoms persist with treatment:
i. Review diagnosis
ii. Treat IBS & constipation (high fiber diet, adequate fluid intake)
iii. Use alternative medical or surgical treatments
5. Progestogens
a. Induces amenorrhea
b. Long term effect if 100% compliance
c. Used for
i. those contraindicated for COCP
d. Types
i. Long acting reversible contraceptives (LARC)
ii. Depot medroxyprogesterone acetate
iii. Levonorgestrel intrauterine system (LNG-IUS) (Mirena)
6. Gonadotrophin releasing hormone agonist (GnRH-a)
a. GnRH-a is used for
i. Diagnosis of endometriosis
ii. Relieving severity and symptoms
 b. Available forms
i. Intranasal spray
ii. Slow release depot formulations (common)
c. Use >6m  drug induced osteoporosis
i. Stop use before then
ii. Cessation  rapid recurrence of symptoms
7. Other hormonal agents
a. Aromatase inhibitors
i. Aromatase converts androgens  estrogens
ii. Aromatase is over expressed in endometriotic tissue
b. Ovarian suppressive agents (danazol & gestrinone)
i. NO LONGER used
1. Androgenic side effects: weight gain, acne, changes
2. Deepens voice
3. Alters lipid profile
4. Alters liver function
8. Surgical treatment
a. Fertility sparing surgery
i. Most surgery for endometriosis can be achieved laparoscopically.
ii. Symptomatic endometriotic chocolate cysts
1. Treatment
a. drain cyst
b. excise inner cyst lining (reduces the risk of recurrence)
i. Associated with damage to functional ovarian tissue.
ii. For fertility preservation: do only drainage
iii. Superficial peritoneal endometriosis
1. Treatment
a. Laparoscopic diathermy or laser
iv. Specialist surgery
1. For when endometriosis has caused
a. extensive adhesions distorting normal pelvic anatomy
b. involved other organs (rectum, large bowel or bladder)
c. rectovaginal nodules of disease.
v. Conservative surgery
1. Recurrent risks up to 30% and therefore concurrent long-term medical therapy is often
necessary and started straight after surgery
b. Hysterectomy and oophorectomy
i. Considered only in women who have completed their family and failed to respond to more
conservative treatments.
ii. Hysterectomy will not necessarily cure the symptoms or the disease.
iii. Hormone replacement therapy
1. Estrogen-only HRT
a. Wait up to 6 months after surgery to prevent activation of any residual disease.
2. Combined (oestrogen and progestogen) HRT
a. A suppressive treatment where reactivation of new or residual disease is suspected.