Medications can be used to reduce the cyclic hormonal stimulation of these lesions and eventually decidualize or atrophy the lesions. No studies directly compared medical versus surgical management of endometriosis. However, given the excellent response rate, relatively low cost, and fair tolerability with hormonal therapy, an expert consensus panel recommended that women with suspected endometriosis who are not actively trying to conceive and who do not have an
Management of Endometriosis: Surgical adnexal mass start with first-line medical management before laparoscopy. First-line treatment consists of a trial of NSAIDs with or without combined estrogen-progestin formulations (53). Both cyclic and continuous combined oral contraceptives (OCs) can be used with equal efficacy (54). Most studies used OCs containing low-dose estrogen and more androgenic progestins; however, newer generation progestins are also effective. For women who continue to have dysmenorrhea after using hormonal contraceptives in a cyclical fashion, continuous OCs regimen can be tried, without a hormonal break or with menstruation every 3 months.
Second-line medical therapy involves high-dose progestins or gonadotropin-releasing hormone (GnRH) analogues. This can be initiated for refractory symptoms or for patients with contraindication to estrogen. Progestins alone are associated with few metabolic concerns and are safe and inexpensive alternatives to surgical intervention. Progestins or progestins plus estrogen effectively manage pain symptoms in approximately three-quarters of the women with endometriosis (55). High-dose medroxyprogesterone acetate and norethindrone acetate are equally effective to the GnRH analogues (56). Progestins should be given at a dose to achieve amenorrhea, then the dose can be tapered to control symptoms.
A randomized controlled trial comparing levonorgestrel intrauterine system (LNG-IUS) with depot GnRH for the treatment of endometriosis-related chronic pain found that both were effective treatments (57).
Androgenic hormones such as danazol are thought to inhibit the luteinizing hormone surge and steroidogenesis and may have anti-inﬂammatory effects. These medications increase free testosterone, resulting in possible side effects such as deepening of voice, weight gain, acne, and hirsutism. Vaginal danazol in lower doses may be effective.
GnRH agonist and add-back treatment can be used as pharmacologic treatments for endometriosis (58). A randomized-controlled trial of GnRH agonist therapy for 6 months in cases of confirmed endometriosis showed decreased size of endometriotic lesions and pain symptoms. Side effects are related to the hypoestrogenic state and include vasomotor symptoms, mood swings, vaginal dryness, decreased libido, myalgias, and, eventually, bone loss. These side effects can be reduced with supplemental calcium and hormonal add-back therapy with norethindrone acetate 2 to 5 mg daily with or without low-dose estrogen (0.625 mg of conjugated estrogen or 1 mg of 17 β-estradiol) (58). Given the side effects, GnRH agonists usually are not used for more than 8 to 12 months, but with add-back hormones and/or bisphosphonate, GnRH therapy can be considered for use for more than 1 year. Recurrence of symptoms after discontinuation of GnRH agonist ranges from 36% to 70% 5 years after completion of treatment.