Treatment for Pain
Your doctor will consider your symptoms, physical examination, test results, and your goals and concerns before advising treatment. Women with mild symptoms may benefit from lifestyle changes or require no treatment at all. Hormonal therapy may be suggested when pain interferes with family, work, or daily activities, since these therapies usually reduce pelvic pain and dyspareunia in more than 80% of women in whom endometriosis is diagnosed. Since several effective treatments are available, the choice is made based on side effects and cost. Hormonal treatments are not effective for large ovarian endometriomas, and surgery is necessary. Surgery also may be indicated when medical treatment is unsuccessful or when medical conditions prohibit the use of hormone treatments.
Lifestyle Modifications
Some women have found that their pain is improved by exercise and relaxation techniques. Although natural supplements have not been shown to reduce endometriosis-related pain, over-the-counter, non-steroidal, anti-inflammatory medications, like ibuprofen and naproxen, reduce painful menstrual cramps. When painful intercourse is a problem, changing positions prevents pain caused by deep penetration. In spite of these measures, medical treatment is frequently needed.
Hormonal Contraceptives
Birth control pills often reduce menstrual cramping and pelvic pain that may be associated with endometriosis. No one pill appears to be better than any other when treating endometriosis symptoms.
Birth control pills may be prescribed continuously without pausing for menstrual periods to women with endometriosis. Side effects of this approach include fluid retention and irregular spotting or bleeding. Serious side effects of birth control pills are very rare and include stroke, vascular problems, and heart disease. It also should be noted that endometriosis may be diagnosed in women taking birth control pills and that birth control pills have never been shown to prevent the development of endometriosis. No data are currently available concerning the effect of transdermal contraceptive patches and vaginal contraceptive rings upon endometriosis.
Birth control pills may be prescribed continuously without pausing for menstrual periods to women with endometriosis. Side effects of this approach include fluid retention and irregular spotting or bleeding. Serious side effects of birth control pills are very rare and include stroke, vascular problems, and heart disease. It also should be noted that endometriosis may be diagnosed in women taking birth control pills and that birth control pills have never been shown to prevent the development of endometriosis. No data are currently available concerning the effect of transdermal contraceptive patches and vaginal contraceptive rings upon endometriosis.
Progestins
Progestins are synthetic medications that have progesterone-like activity upon the endometrium, the uterine lining. Many progestins have been demonstrated to reduce endometriosis-associated pelvic pain. The most common side effects of progestin therapy are irregular uterine bleeding, weight gain, water retention, breast tenderness, headaches, nausea, and mood changes, particularly depression. Progestins are considerably less expensive than other medications and may be prescribed as pills, injections, or the levonorgestrel-containing intrauterine contraceptive devices (IUDs). Drawbacks of the injectable form known as depot medroxyprogesterone acetate is that it may inhibit fertility for many months after treatment is discontinued and that its use for longer than six months may cause a significant loss of bone mineral density and place a woman at risk for osteoporosis.
Gonadotropin-releasing Hormone (GnRH) Analogs
GnRH analogs, particularly GnRH agonists, cause estrogen levels to fall to menopausal levels, and menstruation does not occur. These drugs are highly effective for painful endometriosis. Side effects include menopausal symptoms: hot flashes, vaginal dryness, and loss of calcium from the bones. The medications are usually given for six months. Low-dose estrogen-progestin hormone therapy or progestins alone may be added to prevent bone loss when prolonged treatment is needed or if menopausal symptoms
are severe. Calcium supplementation and exercise are recommended to reduce the loss of bone density that occurs with therapy. Most bone density loss is temporary and is regained after treatment is stopped. In a recent comparative trial, GnRH agonist therapy with leuprolide acetate and progestin therapy with depot medroxyprogesterone acetate for subcutaneous injection (DMPA-SC) were equally effective in reducing endometriosis-associated pain; both medications maintained clinical improvement for 12 months following the end of treatment. DMPA-SC was associated with less bone loss and fewer hot flashes than depot leuprolide.
are severe. Calcium supplementation and exercise are recommended to reduce the loss of bone density that occurs with therapy. Most bone density loss is temporary and is regained after treatment is stopped. In a recent comparative trial, GnRH agonist therapy with leuprolide acetate and progestin therapy with depot medroxyprogesterone acetate for subcutaneous injection (DMPA-SC) were equally effective in reducing endometriosis-associated pain; both medications maintained clinical improvement for 12 months following the end of treatment. DMPA-SC was associated with less bone loss and fewer hot flashes than depot leuprolide.
Zoladex
Zoladex (Goserelin) is a synthetic analogue (artificial copy) of the natural female hormone Gonadotrophin Releasing Hormone (GnRH) and is a GnRH agonist (works against). Zoladex is made by AstraZeneca.
How Zoladex works?
Zoladex works by blocking the production of natural Follicle Stimulating Hormone (FSH) and Leutinising Hormone (LH), which are produced by the pituitary gland at the base of the brain. Without FSH and LH the ovaries will not produce oestrogen and the body is tricked into a pseudo (false) menopause. This will reduce the growth of the deposits of endometriosis and cause them to shrink. Zoladex reduces the symptoms of endometriosis including the pain.
During the early days of treatment with Zoladex, some women experience vaginal bleeding which usually stops without any treatment.
During the early days of treatment with Zoladex, some women experience vaginal bleeding which usually stops without any treatment.
Administration and Dosage of Zoladex
- Zoladex comes as a single dose syringe applicator with 3.6mg depot injection (it slowly releases the drug over four weeks)
- Zoladex is given as a single injection into the abdomen subcutaneously (under the skin) every four weeks
- Zoladex can be started at any time during the monthly cycle and is given for a course of six months maximum
- Zoladex is not suitable for the treatment of children
When Zoladex should not be used?
- Pregnancy
- Lactating women (breast feeding)
- Known hypersensitivity to GnRH Analogues
Precautions in the use of Zoladex
- Zoladex should not be used for more than one course of six months as it can cause loss of bone densit
- Zoladex should be used with caution in women with known metabolic bone disease
Reaction of Zoladex with food/alcohol/drugs
No reactions with food, alcohol or drugs have been reported
Side effects of Zoladex
- Hot flushes
- Dry vagina
- Mood changes
- Headache
- Sweating
- Loss of sex drive
- Depression
- Change in breast size
The above side effects seldom require that the treatment be stopped.
Rarely, some women enter menopause during the treatment and their periods do not restart when treatment is stopped. This could happen if a woman is nearing the natural menopause. Zoladex may cause cramps/contractions of the cervix.
As with all treatments there may be no side effects at all, or there may be a few but it is rare to experience multiple side effects
Surgery for Pain
Surgical treatment of endometriosis often is performed when endometriosis is diagnosed. Laparoscopy is usually the first-line treatment for endometriosis. Laparoscopy is when a lighted telescope is placed through an incision below the belly button to view the pelvic cavity. During laparoscopy, the doctor may remove adhesions, endometriotic nodules, and ovarian cysts. Laparoscopy often is used to treat recurrent endometriosis when the goal is to preserve future fertility. Sometimes the severity of endometriosis is such that major surgery is advised to remove endometriosis and adhesions. Removal of the entire ovarian cyst with its wall is superior to merely draining the endometriotic cyst for treating pain and prevention of recurrent cysts.
Overall, fertility-preserving endometriosis surgery improves pain for 60% to 80% of women. After surgery, medical therapy may be needed to control symptoms of endometriosis because 40% to 80% of women experience recurrent pain symptoms within two years of surgery. Recurrent symptoms occur within 5 to 10 years in more than 50% of women after completing a 6-month course of medical treatment. Long-term management of endometriosis-related pain usually is necessary.
Hysterectomy (removal of the uterus) with removal of the ovaries is an effective approach to definitively treat endometriosis after childbearing is completed. This surgery provides final relief from endometriosis-related pain in more than 90% of women. In contrast, if one or both ovaries are preserved, there is a much greater chance that symptoms will recur, and additional surgery will be required. If needed, low-dose hormone therapy (estrogens or progestins) reduces hot flashes and menopausal symptoms that occur after hysterectomy with bilateral removal of the ovaries.
Overall, fertility-preserving endometriosis surgery improves pain for 60% to 80% of women. After surgery, medical therapy may be needed to control symptoms of endometriosis because 40% to 80% of women experience recurrent pain symptoms within two years of surgery. Recurrent symptoms occur within 5 to 10 years in more than 50% of women after completing a 6-month course of medical treatment. Long-term management of endometriosis-related pain usually is necessary.
Hysterectomy (removal of the uterus) with removal of the ovaries is an effective approach to definitively treat endometriosis after childbearing is completed. This surgery provides final relief from endometriosis-related pain in more than 90% of women. In contrast, if one or both ovaries are preserved, there is a much greater chance that symptoms will recur, and additional surgery will be required. If needed, low-dose hormone therapy (estrogens or progestins) reduces hot flashes and menopausal symptoms that occur after hysterectomy with bilateral removal of the ovaries.
Pregnancy
Although it has not been proven that pregnancy is therapeutic, endometriosis often regresses during pregnancy. The hormonal environment produced by pregnancy may inhibit the condition. However, endometriosis often returns some time after pregnancy. A woman must carefully consider her immediate and long-term goals before choosing pregnancy as a treatment for endometriosis.
Team Approach
Some women continue to experience severe pain in spite of hormonal and surgical treatments. When pain persists, a multidisciplinary “team” approach may be helpful. This approach combines the expertise of a group of specialist physicians at a “pain center,” along with mental health specialists, counselors, and physical therapists. Nerve blocks, acupuncture, or other treatments may be beneficial.
Investigational Drug Treatments for Endometriosis
A number of new drugs are under research and development for endometriosis. Antiprogestins, such as mifepristone and onapristone, have had success in small studies. These medications work by modulating the estrogen and progesterone receptors in endometriosis implants and causing atrophy of endometriosis. Selective estrogen receptor modulators (SERMs) may be effective by virtue of their antiestrogen effect. Raloxifene is the SERM that currently shows some promise. In contrast, tamoxifen, another SERM, may cause endometriosis to worsen. Aromatase inhibitors, medications that inhibit aromatase, an enzyme that is required for estrogen synthesis, have had success in small studies and case reports. Anastrozole and letrozole are two examples of aromatase inhibitors undergoing investigation. Leukotriene antagonists theoretically will improve dysmenorrhea by modulating the activity of leukotrienes, immune chemicals that contribute to inflammation and pain. Other immune modulators are under investigation in animal models as potential therapies for endometriosis. These include loxoribine, levamisole, interleukin-12, and interferon-alpha-2b.