Endometriosis is the presence of islands of endometrium (i.e., the inside lining of the uterus that women menstruate every cycle) in locations outside of the uterus. Cyclic changes in these cells can be associated with localized bleeding and pain. The exact reason for the development of endometriosis is unknown.
A tendency to inherit endometriosis has been identified; 8-10% of women with endometriosis have first degree relatives (mother or sister) with the disease. Women in affected families develop endometriosis at an earlier age and are more likely to have advanced disease.
On examination, your physician can sometimes feel changes in the pelvic structures suggestive of endometriosis. These changes include the presence of cysts on the ovaries, scarring around the uterus, and painful nodules around the support ligaments to the uterus.
Laparoscopy is the only definitive diagnostic tool used in making a diagnosis of endometriosis. The smallest areas of growth appear as blue-black raised lesions covering the surfaces of the internal organs. Older lesions are often puckered as a result of scarring. Larger lesions can form cysts on the ovaries called endometriomas
Ultrasound and blood work cannot confirm the presence or absence of endometriosis.
For infertile women with endometriosis, the infertility evaluation should be completed and all potential factors contributing to infertility should be addressed. Endometriosis can be treated with either medications or surgery. A variety of different drugs have been used to treat endometriosis.
The role of medications in the treatment of infertility is limited and the following medications have been shown to be effective in control of pain due to endometriosis.
Oral contraceptive pills
Treatment with estrogen and progesterone combination hormone therapy (oral contraceptives) has been used in order to create a stable hormonal environment that does not stimulate endometriosis. By establishing such a hormonal state, endometriosis has been found to stop growing and symptoms have resolved partially or completely. In general, oral contraceptive pills are the first-line therapy.
Therapy with medication alone is most beneficial in mild to moderate disease. Pain is usually relieved and in over 75% of patients, an improvement of disease has been observed.
Other oral medications include Provera, Depo-Provera and Danazol. Such medications are options but not used often because of the side effects. Indications for these medications are individualized for your personal medical situation and should be discussed in detail with your SRM physician.
Leuprolide Acetate (Lupron® injection or Lupron Depot®) is a hormone-like medication taken as a daily or monthly injection. The drug works by blocking or suppressing the release of hormones from the pituitary gland, namely follicle stimulating hormone (FSH) and luteinizing hormone (LH). If the ovaries are not exposed to FSH and LH, then the ovaries essentially become dormant temporarily, and do not release any of their normal hormones (e.g.- estrogens and androgens), and the normal follicular development that results in ovulation also does not occur.
Because the estrogen levels are reduced by the GnRH agonist (Synarelâ or Lupronâ), processes that are estrogen dependent such as fibroid tumors or endometriosis tend to decrease in size and become less of a problem within a month or two of starting the leuprolide acetate therapy.
Therapy usually lasts between 3 and 6 months. For a period of time after stopping the treatment - often up to one or three months after treatment stops, most women do not have return of their monthly menstrual periods. However, menstruation does return similar to the way it was before therapy.
GnRH agonists acetate seems to be safe. There is no evidence of increased congenital anomalies in pregnancies that occur following leuprolide acetate therapy, nor does it appear to have any adverse effects on fertility. This therapy will keep you from becoming pregnant while on the medication. However, you should not rely on this as a method of contraception, and you should use a barrier method of contraception during this treatment such as a diaphragm or condoms.
The goal in treatment of endometriosis is to improve the associated symptoms, such as severe menstrual cramps, pain with sexual intercourse (dyspareunia), pelvic pressure and pelvic pain, and /or bowel or bladder problems. Since endometriosis is dependent on estrogen, the GnRH agonists may dissolve the spots of endometriosis and /or shrink any ovarian cyst related to this condition (endometrioma). After therapy, however, endometriosis may grow again, so follow-up examinations are necessary.
Surgical removal of areas of endometriosis involves laparoscopy, a procedure done on an outpatient basis. Medical and surgical treatments are sometimes combined in order to facilitate surgical removal of endometriosis and diminish post operative recurrence.
Despite such therapy, endometriosis can be a difficult to deal with because of its recurrence. In general, the more severe, the greater chance of recurrence.
Potential Risks and/or Side-Effects
Currently, no major adverse side-effects in humans have been documented. Side-effects of leuprolide acetate therapy include the following:
- Temporary discontinuation of menstrual periods
- Hot flashes
- Temporary mild worsening of the disease (e.g. endometriosis) early in treatment
- Local skin reaction or bruising around injection site
- Bone loss, which is usually reversible, has been shown to occur after a 6 month course of therapy
- Head aches, vaginal dryness, mood swings
Management of endometriosis should be strictly individualized to each patient. This concept is of great importance in treating the infertile couple and all women with endometriosis. An SRM physician will review the specific recommendations in your situation whether it is the treatment of pain or infertility due to endometriosis.