How do we treat Endometriosis?
Currently there is no perfect way to treat endometriosis. There are basically three approaches to therapy:
Watchful waiting: Treatment involves relieving symptoms only.
Hormonal therapy: Aimed at reducing endometrial implants.
Surgical therapy: Aimed at reducing endometrial implants and restoring fertility.
The choice of treatment depends on the patient’s symptoms, her age, her desire to have children, and the severity of the disease. Watchful waiting is a good initial choice for women with mild disease and no desire to become pregnant, however most women with moderate to severe symptoms or a desire to become pregnant need more proactive treatment.
Hormonal Therapy for Endometriosis
Hormonal therapies are used to mimic states in which ovulation does not occur (such as pregnancy or menopause) or to directly block ovulation. Common agents include oral contraceptives, progestins and GnRH agonists, while danazol is less commonly used. These can be very effective in reducing the symptoms of endometriosis.
However there are downsides associated with hormonal therapy:
- Hormonal agents do not cure endometriosis.
- Symptoms recur in about half of patients within 5 years of treatment.
- They no do not improve fertility rates and will delay conception in women who use them.
Surgical Therapy for Endometriosis
Surgery is an option for women with severe symptoms that don’t respond to hormonal therapies, and for women who wish to become pregnant. The most common surgical approach to endometriosis in women desiring pregnancy involves using laparoscopy (insertion of a camera and instruments through two small incisions in the abdomen) to remove endometrial implants without removing any reproductive organs.
This is called conservative surgery.
The goal of the procedure is to remove as many endometrial implants and cysts as possible without causing surgical scarring and subsequent adhesions that could increase fertility problems. Conservative surgery has been shown to improve rates in women with moderate to severe endometriosis. Surgery has also been shown to have a positive effect on fertility in women with mild endometriosis although the improvement in fertility may be small. Therefore, most doctors recommend surgery even in early-stage endometriosis because of the progressive nature of the disorder and evidence that it improves fertility.
Surgery has been shown to reduce pain associated with endometriosis in 60% of women. Conservative surgery, however, can miss microscopic implants that may continue to cause pain and other symptoms after the procedure. Even with very successful surgery, endometriosis usually recurs within a period of two months to several years. The risk of recurrence appears to be highest in women with severe endometriosis. The use of GnRH agonists (one of the hormonal therapies) after surgery may delay recurrence without affecting fertility.
You and your doctor will decide which treatment is best for you based on your age, your symptoms, the severity of your disease, and whether you wish to become pregnant.
More information may be found at the following websites:
The Endometriosis Association: www.endometriosisassn.org
American Society for Reproductive Medicine: www.asrm.org
International Pelvic Pain Society: www.pelvicpain.org