Women with endometriosis often present for medical care for one or more of the following health issues: pelvic pain, infertility, and/or an adnexal cyst (endometrioma). For women with moderate or severe pelvic pain and laparoscopically diagnosed endometriosis, hormone therapy is often necessary to achieve maximal long-term reduction in pain and optimize health. I focus on opportunities to optimize hormonal treatment of endometriosis in this editorial.
When plan A is not working, move expeditiously to plan B
Cyclic or continuous combination estrogen-progestin contraceptives are commonly prescribed to treat pelvic pain caused by endometriosis. Although endometriosis pain may initially improve with estrogen-progestin contraceptives, many women on this medication will eventually report that they have worsening pelvic pain that adversely impacts their daily activities. Surprisingly, clinicians often continue to prescribe estrogen-progestin contraceptives even after the patient reports that the treatment is not effective, and their pain continues to be bothersome.
Patients benefit when they have access to the full range of hormone treatments that have been approved by the FDA for the treatment of moderate to severe pelvic pain caused by endometriosis (TABLE). In the situation where an estrogen-progestin contraceptive is no longer effective at reducing the pelvic pain, I will often offer the patient the option of norethindrone acetate (NEA) or elagolix treatment. My experience is that stopping the estrogen-progestin contraceptive and starting NEA or elagolix will result in a significant decrease in pain symptoms and improvement in the patient’s quality of life.
Other FDA-approved options to treat pelvic pain caused by endometriosis include depot medroxyprogesterone acetate injectable suspension, depot leuprolide acetate, goserelin implant, and danazol. I do not routinely prescribe depot medroxyprogesterone acetate because some patients report new onset or worsening symptoms of depression on the medication. I prescribe depot-leuprolide acetate less often than in the past, because many patients report moderate to severe hypoestrogenic symptoms on this medication. In women taking depot-leuprolide acetate, moderate to severe vasomotor symptoms can be improved by prescribing NEA pills, but the alternative of norethindrone monotherapy is less expensive. I seldom use goserelin or danazol in my practice. The needle required to place the goserelin implant has a diameter of approximately 1.7 mm (16 gauge) or 2.1 mm (14 gauge), for the 3.6 mg and 10 mg doses, respectively. The large diameter of the needle can cause pain and bruising at the implant site. As a comparison, the progestin subdermal implant needle is approximately 2.1 mm in diameter. Danazol is associated with weight gain, and most women prefer to avoid this side effect.
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