April 24, 2020
Author Name: Dr. M Nandini Devi || Mentor Name: Dr. Shubhdeep Bhattacharya on April 24, 2020
Endometriosis is a mystifying disease. It is the most common gynaecological disease affecting the women of reproductive age.
It afftects almost 10% of the women of reproductive age group. 25-48% of women with infertility suffer from endometriosis.
Endometriosis is defined as a chronic disease in which, the tissue similar to the lining of uterus(endometrium) grows outside the uterus, i.e., in other places in the body. Endometriosis commonly involves ovaries, fallopian tubes,tissues lining the pelvis, rarely spreads beyond the pelvic organs.
It mainly causes pain and inability to conceive.
Currently, there is no permanent cure for endometriosis. There are treatment options available to alieviate pain and for infertility.
When a doctor treating a patient with endometriosis he/she will consider the following points, before commencing a treatment:
1. Age of the patient
2. Severity of the symptoms
3. Severity of the disease
4. Whether the patient wants to conceive
We will be discussing, about the cure for endometriosis under 2 broad headings:
1. Treatment for Infertility- related to Endometriosis
2. Treatment for Pain associated with Endometriosis
Treatment for Infertility- related to Endometriosis
When a patient with endometriosis presenting with infertility, we need to do a detailed infertility work up. We need to consider the following factors while treating patients with infertility related to endometriosis:
1. Age of the patient
2. Extent of the disease
3. Stage of the disease
4. Duration of infertility
5. Any previous surgeries
6. Priority of the patient
When a couple presents with infertility, medical management may not be helpful in achieving pregnancy, as these drugs have contraceptive effect, i.e., patient may not conceive till they are taking those medications. They are effective only in the pain management.
In case of minimal to mild endometriosis, performing laparoscopic cystectomy, ablating the endometrial implants and releasing the adhesions, can improve the fertility potential of the patient. Couple should plan their pregnancy after the surgery. They should not leave more space between the surgery and the pregnancy.
For Stage I/II endometriotic patients, first line treatment option would be Intrauterine insemination, as this increases the chance of pregnancy. Couples can try 3-4 cycles of IUI. If they are not able to achieve the pregnancy, within these 3-4 cycles of IUI, then they should try IVF/ICSI cycle.
When a patient having severe endometriosis, associated with tubal block, or decreased ovarian reserve / along with husbands abnormal semen analysis then proceeding with IVF/ICSI cycle(artificial reproductive techniques) directly would be the best option.
Treatment for Pain associated with Endometriosis:
Empirical treatment to be started based on patients symptoms, after a thorough counselling. Empirical treatment for pain includes:
Pain relievers may be prescribed when pain is mild. These medications are available over-the-counter. Most commonly used pain relievers are nonsteroidal anti-inflammatory drugs, NSAIDS.
Hormonal therapy is used to treat the pain associated with endometriosis. It is available in the form of a pill, injection, or nasal spray. These treatments, cause the ovaries to stop producing hormones, thereby preventing ovulation. It slows the growth and activity of both the endometrium and endometrial lesions.
Oral contraceptive pills:
This makes menstrual cycles regular, lighter and shorter and relieves pain. Pain relief lasts till the patient takes the pill. After stopping the treatment, the symptoms may return.
Side effects: Usually mild, such as weight gain, bloating, spotting.
Gonadotropin releasing hormone(GnRH agonist):
GnRH agonist cease the production of hormones to prevent ovulation, menstruation and the growth of endometrial implants. This may be given for only about 6 months at a time. After stopping this treatment, the symptoms may recur.
Side effects: Hot flushes, tiredness, headache, bone loss, vaginal dryness, sleep problems, depression.
Progestin therapies which includes, contraceptive injection(Depo-provera), Levonorgestrel containing intrauterine device(Mirena), contraceptive implant can cease the menstrual cycle and control the growth of endometrial implants, thereby relieve the symptoms of endometriosis.
Side effects: Weight gain, depression, irregular vaginal bleeding.
Danazol halt the hormones that are involved in menstrual cycle. Its side effects are severe compared other hormone treatments.
Side effects: Acne, weight gain, fatigue, sore breasts, headache, hot flashes, deepening of voice.
Conservative surgeries like laparoscopic cystectomy, ablating the endometrial implants, while preserving the uterus and ovaries, may increases the chance of conception and alleviate the pain, but may not completely cure the disease.
Hysterectomy with removal of ovaries:
Removal of uterus can be the last resort, in woman who finished her family and not relieved of her symptoms with conservative treatment.
Although, there is no permanent cure for endometriosis, effective treatment options are available for the pain management and infertility related to endometriosis.
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