Endometriosis: Drug Therapy

Therapy goals

  • Improvement of the symptomatology, esp. pain reduction.
  • Fertility preservation (preservation of fertility).
  • Progression prophylaxis (measures to avert the progression of a disease).
  • Relapse prophylaxis (measures to avert a recurrence of a disease).

Therapy indications

  • Pain
  • Involuntary childlessness/infertility
  • Impending organ loss
  • Bleeding (e.g., rectal bleeding/bleeding from the rectum due to endometrial rectal infiltration) or acyclic bleeding (in cases of adenomyosis/endometrial involvement of the myometrium).
  • Urinary retention due to endometriosis-related ureteral stenosis, spontaneous bowel perforation, or bowel stenosis [absolute indications].

Therapy recommendations

The following is the therapeutic procedure:

  • Symptomatic therapy:
    • Analgesics
    • Spasmolytics
  • Endocrine therapy (hormone therapy) can be used (neo-)adjuvant (to achieve improved baseline for surgery/supportive) and recurrence (recurrence):
  • See also under “Further therapy“.

Analgesics

Analgesics are pain relievers. There are several different subgroups, such as the NSAIDs (non-steroidal anti-inflammatory drugs) to which ibuprofen and ASA (acetylsalicylic acid) belong, or else the group around the non-acid analgesics paracetamol and metamizole. They are all widely used. Many of the drugs in these groups carry a risk of gastric ulcers (stomach ulcers) with prolonged use. In endometriosis, they may be used purely symptomatically for minor focal lesions when menstrual pain is the primary complaint.

Endocrine therapy (hormone therapy)

In endometriosis, continuous administration of estrogen-progestin combinations can be used to inhibit the body’s secretion of sex hormones. This leads to resorption of the endometriosis lesions. However, these preparations are no longer regularly used due to severe side effects. The administration of progestogen-only preparations leads to pain relief in addition to the reduction of the endometriosis lesions. However, these preparations also have strong side effects.

Gonadotropin-releasing hormone (GnRH) is a hormone produced in the hypothalamus that is superordinately responsible for the release of sex hormones. GnRH agonists – which include buserelin or goserelin – mimic the action of natural GnRH. Initially, these stimulate the pituitary gland to produce FSH and LH (so-called “flare-up effect”). However, with continued use, suppression of these hormones sets in as the pituitary gland becomes fatigued and unresponsive (so-called “down-regulation”). GnRH therapy should be limited to a maximum of 6 months. Due to the sometimes considerable side effects resulting from the estrogen deficiency, the so-called “add-back” therapy, concomitant administration of progestin or estrogen-progestin combinations, has proven effective. To reduce side effects, GnRH analogues are occasionally also given in half the therapeutic dose or a descending (draw-back therapy) dose.