Treatment of Endometriosis
Treatment objectives are to reduce and eliminate any pain and improve fertility. Both medical and surgical treatment must be individualised to each patient, taking into account the clinical manifestations, severity, extent and location of the endometrial implants, treatment response and tolerance, and the patient’s age, wishes regarding fertility and opinion.
Non-drug treatment of Endometriosis
Endometriosis is categorised as a chronic multifactorial disease. Its management aims to control the disease from the moment of its diagnosis until the onset of menopause, while considering the possibility of pregnancy during this period.
As with other pathologies, it is very important to promote healthy lifestyle habits:
Healthy diet. There is no evidence to suggest a given diet cures endometriosis, but the benefits of a healthy diet will help alleviate the symptoms and above all control hormonal imbalances and clinical aspects associated with any intestinal changes. Try to reduce the consumption of socalled pro-inflammatory foods (dairy products, red meat, sugars, caffeine, chocolate,...) these increase the production of PGE2 prostaglandins which are involved in the inflammatory process and therefore generate pain, and oestrogen-boosting foods.
Regular physical exercise. Helps improve patients’ physical condition and mood.
Avoid toxic agents such as tobacco and alcohol.
There is no clear evidence concerning the best medical treatment in terms of controlling the symptoms and evolution of the disease.
Early treatment usually involves the combination of painkillers with non-steroidal anti-inflammatory drugs (NSAIDs) and hormonal contraceptives (primarily gestagens, oestro-progestogens and gonadotropin-releasing hormone analogues [GnRH analogues]). Generally, all treatments that generate amenorrhoea (absence of menstruation) and/or suppress ovulation and/or decrease menstruation frequency and/or decrease the amount of menstrual flow will improve the painful symptoms associated with endometriosis.
Combined hormonal contraceptives, oestro-progestogens (taken orally, transdermally or vaginally), are considered the first-line treatment. Second-generation gestagen oral contraceptives administered at moderate doses are the preferred option. Progestogens (medroxyprogesterone acetate, norethisterone acetate, dienogest, desogestrel) have also proven to be effective for pelvic pain due to endometriosis.
Another possibility with proven effectiveness and considered as a first-line treatment is the use of levonorgestrel-releasing intrauterine devices (IUD Mirena®) which can be left inside the uterus for up to 5 years.
The most common surgical interventions for the treatment of endometriosis are:
Cystectomy. An operation to remove ovarian cysts known as endometriomas.
Ovariectomy. Removal of one (unilateral ovariectomy) or both ovaries (bilateral ovariectomy).
Salpingectomy. Removal of one or both Fallopian tubes.
Adnexectomy. Unilateral or bilateral removal of the Fallopian tubes and ovaries.
Adhesiolysis. The release of adhesions to the abdominal cavity generated by the endometriosis or by intercurrent surgical processes.
Hysterectomy. Removal of the uterus, particularly in patients affected by adenomyosis and who have fulfilled their reproductive wishes or do not want to preserve the uterus.
Deep-infiltrating endometriosis management is complex. Highly complex surgical procedures are often required and these have a rate of complications that must be taken into account; therefore they must be performed by gynaecologists experienced in advanced laparoscopy.
A multidisciplinary team (urologist, general surgeon and gynaecologist) shall carry out these interventions, given that extrapelvic intestinal and urinary compromise can often result in the need for adjunct surgical procedures, such as ureteral reimplantation, vesical nodule resection or even an intestinal resection.
Aromatase inhibitors, progesterone antagonists, selective progesterone receptor modulators and selective GnRH receptor antagonists are promising hormone treatments although they are still experimental therapies.
Non-hormone treatments, which are all in experimental stages, are related to the anti-inflammatory capacity of new molecules such as anti-tumour necrosis factor, MIF antagonists (macrophage migration inhibitory factors), PGE2 secretion modulators, etc.
Side effects of treatment
The most common side effects associated with contraceptives are headaches, gastrointestinal disturbances (abdominal distension, nausea), weight gain and cardiovascular changes, which would lead to discontinuation of their use, as well as changes in sexual desire and mood, amongst others. Therefore, each patient’s individual risk must be assessed when selecting an appropriate treatment.
Regarding the use of gonadotropin-releasing hormone (GnRH) analogues for more than 6 months, complications are associated with the risk of bone mass loss (osteoporosis) and the appearance of climacteric symptoms (a natural decrease in the activity of sex glands) which makes it hard to tolerate the therapy. If it is taken for more than 6 months, the co-administration of so-called “add-back” therapies (i.e., the simultaneous administration of oestrogens, progestogens, combinations of oestrogens and gestagens or tibolone) should be assessed to avoid the aforementioned side effects. This means the treatment can be maintained for much longer.
The complications of surgical treatments are related to the adherences associated with repeated interventions which form internal scars in the patient's belly, as well as visceral lesions, alterations in the functionality of the urinary and intestinal system, the fact of suffering recurrences or affect reproductive capacity.