Endometriosis Treatment: focus on medication options.
To recognise Endometriosis Awareness Month, here’s an update on the treatment options.
There are three kinds of treatments for endometriosis:
· Medical treatments (medications)
· Surgical treatments (involving an operation)
· Complementary treatments (physiotherapy, psychology, acupuncture, complementary medicine, etc.)
Let’s focus on medications. Discussion often seems to focus around surgery for endometriosis but almost all people will benefit from medication and input from a team approach to care rather than straight to surgery.
In the past people were often told that endometriosis could only be diagnosed by a laparoscopy and actually seeing the endometriosis lesions in the pelvis with a camera. Now, best endometriosis/pelvic pain care uses specialised ultrasound imaging and sometimes MRI to visualise endometriosis.
These days surgery is increasingly being recommended for cases where pain is not managed by other means or when there are problems falling pregnant. It is complex surgery and needs to be performed by a gynaecologist with advanced endometriosis surgery training. Often other surgical specialities, such as bowel or bladder surgeons, may also be needed to be involved if endometriosis extends to other organs in the pelvis. Ultrasound and MRI are useful tools so surgery can be carefully planned to ensure the best results.
Superficial endometriosis i.e endometriosis tissue which lies on top of the pelvic organs, does not show up well on ultrasound and it is very appropriate to make a working-diagnosis of endometriosis for those who have symptoms but a reported normal pelvic ultrasound. It is advisable to start medical and complementary therapies without waiting for surgery to ‘diagnose endometriosis’.
Sometimes people are worried that not having surgery early will allow the endometriosis to spread. If non-surgical treatments give good pain relief and return to function then outcomes have been shown to be better than multiple-surgical interventions. Most people who have surgery for endometriosis will still be advised to take medications after the surgery to try and suppress endometriosis tissue growth and involve pelvic physiotherapy, dietitians and psychologists to manage the bladder, bowel and sexual issues often associated with endometriosis.
Medical treatments for endometriosis
These can be divided into hormonal and non-hormonal treatments.
Hormonal treatments include the combined oral contraceptive pill (oestrogen and progestogen) and progestogens alone, which can come in many different forms, including tablets, injections, implants and the progesterone-releasing intrauterine device (IUD).
There has been a new medication recently approved for use in Australia for medical management of endometriosis. This medication is a combination of 3 different hormonal preparations which can powerfully suppress endometriosis with less side-effects than some of the older medications. The new medication also provides contraception and should reduce period bleeding. It is available under the trade name Ryeqo.
With the new addition, there are 6 types of medications indicated for the treatment of endometriosis available in Australia.
· Norethisterone (PRIMOLUT N)
· Oral medroxyprogesterone acetate (RALOVERA, PROVERA, DEPO PROVERA, DEPO RALOVERA)
· Nafarelin (SYNREL)
· Dienogest (VISANNE, DINASANE)
· Goserelin (ZOLADEX 3.6 mg implant)
· Estradiol, norethisterone acetate, relugolix (RYEQO)
You should discuss the differences in the treatments with your doctor before starting a treatment. There are advantages and disadvantages to all the types of treatments and you may need to try several treatments of different types before finding the right combination for you. Some can be used safely for many years. Some, Ryeqo included, are only recommended to be used for a few years as they may affect bone density in the long term.
Non-hormonal medications include:
· pain-relieving medications such as paracetamol
· non-steroidal anti-inflammatories (NSAIDs)e.g. mefenamic acid (Ponstan), naproxen (Naprogesic), indomethacin (Voltaren), ibuprofen (Nurofen)
· strong pain relievers such as codeine, oxycodone
· pain modulator medications – including amitriptyline (Endep), duloxetine and gabapentin
These medications are designed to relieve the pain that can be associated with endometriosis, though they are not intended to reduce the amount of endometriosis present. They may be used as a sole treatment or in combination with other treatments.
It is important to maximise the benefit and reduce the side-effects of NSAIDs by taking them as soon as the period pain or bleeding starts. They work much better if taken before the pain gets intense and should be taken regularly 3 to 4 times a day for 3-4 days for menstrual pain. They can also be helpful for non-menstrual pain but they are specifically effective at blocking the prostaglandins which are associated with menstrual ‘period’ pain. They should also always be taken with some food to reduce stomach irritation which can cause upper abdominal pain and nausea.
Codeine and oxycodone may occasionally be needed for very severe pain but it is not advisable to use these every month as they commonly cause constipation which worsens pelvic pain and the human body rapidly adapts to these medications so you need to take more. They may have caused more harm than good for many people with endometriosis in the past.
Medications such as amitriptyline, duloxetine, pregabalin/gabapentin can help calm your nervous system and reduce the pain sensitisation. They are used in lower doses than to treat depression or nerve pain when used for endometriosis but often have the added benefit of reducing anxiety and improving sleep along with reducing pain.
There is much to be learned about endometriosis and the future will bring many more treatment options and prevention strategies. It is a great start that we are having so many more discussions about periods and pelvic pain. Always seek more information and advice from your healthcare providers if you have questions or concerns.
March is Endometriosis Awareness Month
Wear some bright yellow to show you are endometriosis aware!
Further reading
ABC news story https://www.abc.net.au/news/2024-03-02/new-endometriosis-drug-approved-but-expert-says-cost-is-an-issue/103507618
Endometriosis Month https://endometriosisaustralia.org/events/endo-enlightened/
TGA information Ryeqo https://www.tga.gov.au/resources/prescription-medicines-registrations/ryeqo-gedeon-richter-australia-pty-ltd-0
