Medical management of endometriosis

Abstract

Purpose of review While laparoscopic surgery plays a key role in the management of endometriosis, symptoms commonly recur, and repeat surgery comes with increased risk. Medical management, including hormonal and nonhormonal treatment, is vital in managing painful symptoms. This review summarizes recent evidence regarding various medical management options available to treat pelvic pain associated with endometriosis. Recent findings Efficacy of dienogest vs. combined oral contraceptive on pain associated with endometriosis: randomized clinical trial. Once daily oral relugolix combination therapy vs. placebo in patients with endometriosis-associated pain: two replicate phase 3, randomised, double-blind, studies (SPIRIT 1 and 2). A randomized, double-blind, placebo-controlled pilot study of the comparative effects of dienogest and the combined oral contraceptive pill in women with endometriosis. Two-year efficacy and safety of relugolix combination therapy in women with endometriosis-associated pain: SPIRIT open-label extension study. Summary All symptomatic women with suspected endometriosis who are not desiring immediate fertility can be offered suppressive treatment to control symptoms and slow the progression of disease. First-line treatments include the combined oral contraceptive pill and progestogens. Second-line treatments include gonadotropin-releasing hormone agonists and antagonists but current guidelines recommend that these should be reserved for people whose symptoms fail to be controlled by first-line agents. The use of complementary and alternative medicines is also increasing in both volume and number of agents used.

Clinical challenges and therapeutic strategies in women with endometriosis, deep infiltrating endometriosis, and/or adenomyosis undergoing assisted reproductive technologies: a narrative review

“…While medical therapy may reduce lesion size and alleviate pain, it does not enhance spontaneous conception rates. Suppressive hormonal treatments may be considered following endometriosis surgery to control endometriosis-related symptoms and reduce the risk of disease recurrence while awaiting ART ( 5 ). In line with the 2022 European Society of Human Reproduction and Embryology (ESHRE) guidelines, hormonal suppression is not recommended as a strategy to improve natural fertility in women with endometriosis ( 6 ).…”

“…Both disorders have also been correlated with adverse obstetric outcomes, including placenta previa, preterm birth, and higher rates of cesarean delivery. With an average diagnostic delay of seven years, endometriosis is usually diagnosed during reproductive age, often coinciding with the early phase of a woman's professional life ( 4 , 5 ). Age is the most important prognostic factor in IVF outcomes.…”

Clinical challenges and therapeutic strategies in women with endometriosis, deep infiltrating endometriosis, and/or adenomyosis undergoing assisted reproductive technologies: a narrative review

“…While medical therapy may reduce lesion size and alleviate pain, it does not enhance spontaneous conception rates. Suppressive hormonal treatments may be considered following endometriosis surgery to control endometriosis-related symptoms and reduce the risk of disease recurrence while awaiting ART ( 5 ). In line with the 2022 European Society of Human Reproduction and Embryology (ESHRE) guidelines, hormonal suppression is not recommended as a strategy to improve natural fertility in women with endometriosis ( 6 ).…”

“…Both disorders have also been correlated with adverse obstetric outcomes, including placenta previa, preterm birth, and higher rates of cesarean delivery. With an average diagnostic delay of seven years, endometriosis is usually diagnosed during reproductive age, often coinciding with the early phase of a woman's professional life ( 4 , 5 ). Age is the most important prognostic factor in IVF outcomes.…”

Combined pelvic floor training and hormonal therapy for endometriosis pain recurrence: a propensity score-matched study

“…Endometriosis-associated pain is multifactorial, rooted in chronic inflammation, neuroangiogenesis, central and peripheral sensitization, and maladaptive pelvic floor muscle function ( 23 ). Surgical removal of endometriotic lesions does not necessarily resolve the underlying disease process, as evidenced by high recurrence rates in long-term follow-up studies of postoperative hormonal regimens ( 24 ).…”

M2 Macrophages are Major Mediators of Germline Risk of Endometriosis and Explain Pleiotropy With Comorbid Traits

“…They reduce both dysmenorrhea and nonmenstrual pelvic pain at rates around 73% and 56%, with minimal loss of bone density when administered in combination therapy. [ 66 , 67 ] Due to side effects of hypoestrogenic state, these medications can only be used for 6–24 months, limiting their long‐term use. Among progestins, dienogest has been highly used; it is reported to provide equivalent to GnRH pain relief, and injury reduction, with side effects comprising menstrual alterations, osteopenia, headaches, weight gain, and libido reduction.…”

“…Among progestins, dienogest has been highly used; it is reported to provide equivalent to GnRH pain relief, and injury reduction, with side effects comprising menstrual alterations, osteopenia, headaches, weight gain, and libido reduction. [ 67 ] Studies comparing dienogest with combined contraceptives find no difference in pain reduction, but more adverse effects on the combined contraceptives group, comprising abnormal uterine bleeding, mood swings, headache, nausea, and breast tenderness. [ 67 , 68 ] Beside the moderate to more severe side effects, hormonal therapy is not an option for patients planning pregnancy.…”

Clinical challenges and therapeutic strategies in women with endometriosis, deep infiltrating endometriosis, and/or adenomyosis undergoing assisted reproductive technologies: a narrative review

“…While medical therapy may reduce lesion size and alleviate pain, it does not enhance spontaneous conception rates. Suppressive hormonal treatments may be considered following endometriosis surgery to control endometriosis-related symptoms and reduce the risk of disease recurrence while awaiting ART ( 5 ). In line with the 2022 European Society of Human Reproduction and Embryology (ESHRE) guidelines, hormonal suppression is not recommended as a strategy to improve natural fertility in women with endometriosis ( 6 ).…”

“…Both disorders have also been correlated with adverse obstetric outcomes, including placenta previa, preterm birth, and higher rates of cesarean delivery. With an average diagnostic delay of seven years, endometriosis is usually diagnosed during reproductive age, often coinciding with the early phase of a woman's professional life ( 4 , 5 ). Age is the most important prognostic factor in IVF outcomes.…”

Combined pelvic floor training and hormonal therapy for endometriosis pain recurrence: a propensity score-matched study

“…Endometriosis-associated pain is multifactorial, rooted in chronic inflammation, neuroangiogenesis, central and peripheral sensitization, and maladaptive pelvic floor muscle function ( 23 ). Surgical removal of endometriotic lesions does not necessarily resolve the underlying disease process, as evidenced by high recurrence rates in long-term follow-up studies of postoperative hormonal regimens ( 24 ).…”

M2 Macrophages are Major Mediators of Germline Risk of Endometriosis and Explain Pleiotropy With Comorbid Traits

“…They reduce both dysmenorrhea and nonmenstrual pelvic pain at rates around 73% and 56%, with minimal loss of bone density when administered in combination therapy. [ 66 , 67 ] Due to side effects of hypoestrogenic state, these medications can only be used for 6–24 months, limiting their long‐term use. Among progestins, dienogest has been highly used; it is reported to provide equivalent to GnRH pain relief, and injury reduction, with side effects comprising menstrual alterations, osteopenia, headaches, weight gain, and libido reduction.…”

“…Among progestins, dienogest has been highly used; it is reported to provide equivalent to GnRH pain relief, and injury reduction, with side effects comprising menstrual alterations, osteopenia, headaches, weight gain, and libido reduction. [ 67 ] Studies comparing dienogest with combined contraceptives find no difference in pain reduction, but more adverse effects on the combined contraceptives group, comprising abnormal uterine bleeding, mood swings, headache, nausea, and breast tenderness. [ 67 , 68 ] Beside the moderate to more severe side effects, hormonal therapy is not an option for patients planning pregnancy.…”

Clinical challenges and therapeutic strategies in women with endometriosis, deep infiltrating endometriosis, and/or adenomyosis undergoing assisted reproductive technologies: a narrative review

“…While medical therapy may reduce lesion size and alleviate pain, it does not enhance spontaneous conception rates. Suppressive hormonal treatments may be considered following endometriosis surgery to control endometriosis-related symptoms and reduce the risk of disease recurrence while awaiting ART ( 5 ). In line with the 2022 European Society of Human Reproduction and Embryology (ESHRE) guidelines, hormonal suppression is not recommended as a strategy to improve natural fertility in women with endometriosis ( 6 ).…”

“…Both disorders have also been correlated with adverse obstetric outcomes, including placenta previa, preterm birth, and higher rates of cesarean delivery. With an average diagnostic delay of seven years, endometriosis is usually diagnosed during reproductive age, often coinciding with the early phase of a woman's professional life ( 4 , 5 ). Age is the most important prognostic factor in IVF outcomes.…”

Combined pelvic floor training and hormonal therapy for endometriosis pain recurrence: a propensity score-matched study

“…Endometriosis-associated pain is multifactorial, rooted in chronic inflammation, neuroangiogenesis, central and peripheral sensitization, and maladaptive pelvic floor muscle function ( 23 ). Surgical removal of endometriotic lesions does not necessarily resolve the underlying disease process, as evidenced by high recurrence rates in long-term follow-up studies of postoperative hormonal regimens ( 24 ).…”

M2 Macrophages are Major Mediators of Germline Risk of Endometriosis and Explain Pleiotropy With Comorbid Traits

“…They reduce both dysmenorrhea and nonmenstrual pelvic pain at rates around 73% and 56%, with minimal loss of bone density when administered in combination therapy. [ 66 , 67 ] Due to side effects of hypoestrogenic state, these medications can only be used for 6–24 months, limiting their long‐term use. Among progestins, dienogest has been highly used; it is reported to provide equivalent to GnRH pain relief, and injury reduction, with side effects comprising menstrual alterations, osteopenia, headaches, weight gain, and libido reduction.…”

“…Among progestins, dienogest has been highly used; it is reported to provide equivalent to GnRH pain relief, and injury reduction, with side effects comprising menstrual alterations, osteopenia, headaches, weight gain, and libido reduction. [ 67 ] Studies comparing dienogest with combined contraceptives find no difference in pain reduction, but more adverse effects on the combined contraceptives group, comprising abnormal uterine bleeding, mood swings, headache, nausea, and breast tenderness. [ 67 , 68 ] Beside the moderate to more severe side effects, hormonal therapy is not an option for patients planning pregnancy.…”