Option 1No treatment
This option includes expectant management and/or limited use of analgesics and NSAIDs, which may be especially helpful for women with dysmenorrhea, particularly when infertility is the primary complaint. In other instances, this approach may fail to provide adequate relief from pain.
Almost all patients should undergo an initial trial of NSAIDs and/or OCs, using NSAIDs no more than 3 days per month and taking OCs continuously for 12 weeks followed by 1 week of withdrawal. Repeat the OC regimen so that the patient has only 4 withdrawal “periods” per year.
Monitor patients every 3 to 6 months the first year and annually thereafter if they are doing well. If this approach fails, laparoscopy usually is the next step, although a 3-month trial of gonadotropin-releasing hormone (GnRH) agonists may be attempted.
Option 2Ovarian suppression
Achieve this using OCs, progestins, danazol, or GnRH agonists or antagonists.
Oral contraceptives can be given cyclically, but many patients do better with continuous active-ingredient tablets for 3 months, followed by withdrawal for 1 week and then repetition. Monophasic OCs are superior to triphasic formulations.
The best beginning dosage usually is 35 μg of ethinyl estradiol, but this can be decreased if the patient is symptomatic with headaches; it also can be increased for breakthrough bleeding. Norethindrone 0.35 to 0.5 mg daily may be added if the patient is still symptomatic with bleeding.
Transdermal estradiol (0.05 mg or 0.1 mg twice weekly) also may be used if it is better tolerated. Treatment lasts 3 to 6 months.
Progestins alone such as medroxyprogesterone acetate (20 to 30 mg daily) or depot medroxyprogesterone acetate (150 mg every 3 months) suppress gonadotropin secretion and ovarian function but can be associated with breakthrough bleeding, mastalgia, bloating, weight gain, and depression.
Danazol (200 to 400 mg twice daily) functions primarily by suppressing follicle-stimulating hormone and luteinizing hormone from the pituitary gland, thereby creating a hypoestrogenic state. Unfortunately, danazol also is associated with androgenic side effects and for that reason is rarely used today. Still, it can be an effective second-line drug.
Laparoscopic treatment is sometimes combined with ovarian suppression to improve success or facilitate surgery.
GnRH agonists include nafarelin acetate nasal spray (200 μg twice daily), leuprolide acetate as an intramuscular injection (3.75 mg monthly), and goserelin implant (for 3-month release).
GnRH agonists cause hypoestrogenemia (ie, estradiol less than 40 pg/mL) and resultant amenorrhea, which permits regression of endometriosis and relief of symptoms. Side effects include hot flashes in about 90% of patients, decreased libido, vaginal dryness, headaches, emotional lability, and insomnia.
- The problem of bone loss. The major concern with GnRH agonists is the loss of bone density—about 3% to 8%—which occurs over 6 months of drug therapy, with a 2% to 3% loss persisting approximately 1 year after treatment.5 While only one 6-month course of GnRH agonist is approved by the US Food and Drug Administration, studies have shown that 3 months of treatment—both initially and for subsequent retreatment (if symptoms recur)—is as effective as 6 months of treatment and is associated with less bone loss.6,7 Patients generally should undergo dual-photon absorptiometry to confirm that they have normal bone density before beginning GnRH-agonist retreatment. In addition, patients should be fully informed of the potential risks of therapy. Subsequent symptoms also may be treated with OCs, danazol, and/or surgery.
- Hot flashes can be effectively managed with norethindrone (2.5 mg daily). Low doses of estrogen (conjugated estrogen 0.6 mg or estradiol 1 mg per day) have also been used as “add-back” therapy to reduce bone loss. More recently, add-back therapy for 6 to 12 months with norethindrone (2.5 mg daily) and alendronate (10 mg daily) has been suggested, along with calcium (1,000 mg per day).8 While these appear to be effective, the long-term impact of such add-back therapy is still being evaluated.
Option 3Surgical treatment
Laparoscopy enables treatment to be initiated, when appropriate, and possibly completed at the same time as diagnosis. Surgical therapy usually is conservative, consisting of excision, laser vaporization, or electrosurgical coagulation of endometriosis. Adjunctive procedures such as salpingo-ovariolysis also may be performed.
Other controversial but occasionally indicated procedures for pain include uterosacral nerve ablation and, for severe midline dysmenorrhea, presacral neurectomy.
Medical and surgical treatments sometimes have the same results, but surgical treatment completed at the time of diagnosis has a distinct advantage over medical therapy because of the decreased time, cost, and side effects associated with it.
Option 4Combined treatment