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Endometriosis II ( Treatment )
Somkiat Sitavarin MD.
Asso. Prof. Kamthorn Pruksananonda MD. ( Advisor )
Medical treatment of endometriosis
Indication for treatment of endometriosis
• Pain : pelvic pain, dysmenorrhea, or dyspareunia
• Abnormal bleeding
• Pelvic pathology : ovarian cyst
• Infertility
• ? Prophylaxis
Modality of medical treatment for endometriosis
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Nonsteroidal anti-inflammatory drug
Estrogen-progestogen combination : cyclic, continuous
Progestogen : injectable, oral
Danazol
GnRH-a
Antiprogestin
Others
Therapeutic options
Analgesic
• NSAIDS inhibit biosynthesis of PGs and alleviate symptoms
• Well tolerated, safe and inexpensive and are recommended as a
first-line of treatment in mild symtoms
Therapeutic options
Combination of estrogen and progestin ( pseudopregnancy )
• anovulation, amenorrhea and progressive decidualization then
necrobiosis and resorption of ectopic endometrium
• Use of OC. ( .020-.035 mg EE ) continuously 6-9 mos.
• Lowest dose to produce amenorrhea
• Side effects - abdominal swelling, depression,breast pain and
tenderness, increase appetite, weight gain, edema to breakthrough
bleeding.
Combination of estrogen and progestin ( pseudopregnancy )
• Superficial varicosity occasionally appear, and there is an increase
risk of DVT.
• Symptomatic relieve 75-100 %; Pregnancy rate ranged from 10-58
%
• Today, this regimen is not commonly used and initial treatment
Progestogens
Progestogens used for management of endometriosis
Parenteral
• MPA ( Provera )
Oral
• MPA ( Provera )
• Megase
• Gestrinone
• Lyestrenol
• CPA
MPA
• 100 mg DMPA every 2 wks. 4 doses followed by 200 mg
monthly 4 mos.
• When breakthrough bleeding occurred, EE .02 mg daily 25 days
each month was added
• Other regimen consists of 150 mg every 3 mos. For 1 year
• Adequate data to document the effectiveness of MPA to soppress
endometriosis and enhance fertility are not available
• Spotting, depression, breakthrough bleeding, weight gain
Other Progestogen
Gestinone ( R2323 )
• Unsaturated 19-norsteroid
• Is a weak progestin and androgen agonist/ antagonist
• Suppress midcycle LH surgh and FSH and folliculogenesis
• Amenorrhea and symtomatic relieve in 85-90 % within 2 mos
• Side effects were moderate, transient and primarily related to
androgenic and anabolic activities
Megestrol acetate
• Antiandrogenic effect and suppressive action on gonadotropin
• In retrospective study, using 40 mg/day for upto 24 weeks - 86%
relieve symtoms
Dydrogesterone ( Duphaston )
• 20-30 mg/day
• 60 mg in luteal phase
• shown to relieve pain, neither regimen seem to improve pregnancy
rates
CPA
• 17-OH progesterone derivatives
• In combination with EE. may be as effective as danazol to alleviate
pain
• Antiandrogenic, antigonadotropic and progestational activities
• Side effects were fatigue, loss of libido, depression and weightgain
Antiprogestins ( RU 486 )
• Bind to progesterone receptors and exert antiprogesterone and
antiglucocorticoid activities
• Inhibit ovulation and disrupt endometrial integrity
• 100 mg/day for 3 mos. induce amenorrhea and decrease pelvic
pain
• 50 mg/day for 6 mos. alsoso has been report
• Side effects were atypical flushes, anorexia and fatique
Danazol
• Isoxazole derivatives of 17-alpha-ethinyl testosterone
• Androgen and glucocorticoid agonist, suppression of Gn, inhibit
ovarian steroidogenesis and alter immune response
• 400-800 mg/dy for 6 mos. with pregnancy be excluded
• Symtomatic relieve 60-100 %, dyspareunia relieve 80 %
• 0n second look assesment, almost 100 % resolute in minimalmild, 50-70 % in advanced disease
Danazol
• Side effects were weight gain, acne, hirsutism, oily skin and
decrease in breast size, muscle cramp, flushing, mood changes,
depression and edema
• HDL decrease, LDL increase, VLDL not changed ,