Advances in Treatment Options of Endometriosis

Abstract

Endometriosis, defined as the presence of endometrial tissue outside the uterus, is a challenging condition associated with substantial morbidity. Management of endometriosis must be individualized according to the desired treatment outcome, whether it is relief of pain, improvement of fertility, or the prevention of recurrence. For alleviation of endometriosis-associated pain, medical treatment is generally successful, with no medical agent being more efficacious than another in spite of significantly differing side-effect profiles. Surgical therapy has also been demonstrated to reduce pain scores in comparison with expectant management, although conservative surgery has been frequently associated with recurrence. The efficacy of combination therapies still remains to be clarified. For treatment of endometriosis-associated infertility, suppressive medical treatment has been proven to be detrimental to fertility and should be discouraged, while surgery is probably efficacious for all stages. Controlled ovarian hyperstimulation with intrauterine insemination is recommended in early-stage and surgically corrected endometriosis. Combined surgery with GnRH analog treatment has been proposed to be first-line therapy, followed by IVF as second-line therapy in advanced cases. More rigorously designed randomized clinical trials focusing on the endocrinological, immunological, and genetic aspects of endometriosis are necessary to refine conclusions regarding the etiopathogenesis and therapeutic innovations of this perplexing disease.

Endometriosis and Infertility

“…Likewise, multiple randomized trials have evaluated the use of ovarian suppression post-operatively. The aim was to increase resorption of residual deposits and reduce the recurrence of disease, however no trial reported increased fertility rates (59). A 2009 Cochran review looked at 16 trials of pre- or post-operative hormonal suppression and found that there was no evidence of benefit associated with post-surgical medical therapy and insufficient evidence to determine a benefit to pre-operative therapy with regards to pain, disease recurrence or pregnancy rates (74).…”

Unexpected Gynecologic Findings During Abdominal Surgery

“…Women struggling with infertility are up to eight times more likely to have endometriosis than fertile women. 42, 43 Additionally, endometriosis is estimated to occur in up to 60% of women with dysmenorrhoea and up to 87% of women with chronic pelvic pain. 42, 44 The incidence of endometriosis may also be increasing over time.…”

“…42, 43 Additionally, endometriosis is estimated to occur in up to 60% of women with dysmenorrhoea and up to 87% of women with chronic pelvic pain. 42, 44 The incidence of endometriosis may also be increasing over time. 41 Symptoms of endometriosis include dysmenorrhea, dyspareunia, chronic pelvic pain, and pain associated with ovulation, micturition, and defecation.…”

“…Other theories include coelemic metaplasia, lymphatic or vascular embolization of endometrial tissue, and transformation of embryonic rests. 39, 40, 42 Endometrial implants tend to occur asymmetrically in the abdomen, being located on the left more frequently than the right 46 The presence of endometrial tissue causes inflammation, which results in pain, adhesions, and pelvic anatomic distortion. In women with Stage IV disease, pain may be mediated by the presence of deep infiltrating endometrial lesions in the muscularis propria of surrounding organs.…”

“…The use of postoperative hormonal suppression therapy is controversial. 42, 44, 45, 47-49 In stage IV cases, large or small bowel resection, bladder resection, colostomy, and other procedures may be necessary.…”