eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology
Endometriosis: Treatment & Medication
Updated: Feb 14, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
Follow established protocols of resuscitation for unstable female patients of reproductive age with acute abdominal/pelvic pain.
Emergency Department Care
The goal of the emergency physician is to provide pain relief and exclude life-threatening causes of pelvic/abdominal pain.
- Unstable patients require resuscitation and possibly urgent surgical consult.
- Medical management in the ED generally is restricted to pain control. Long-term medical therapy usually is suppressive and rarely curative.
- Medical treatments for endometriosis act in a variety of ways to abolish the trophic effect of estradiol on both the eutopic and ectopic endometrium. Therefore, the patient develops amenorrhea because all endometrial tissue becomes inactive.
- Medical treatment can relieve symptoms, but the recurrence rate is high after cessation of medications.
- All medical treatments are equally effective in managing endometriosis; about 80-85% of patients note improvement in their symptoms.
- The main difference between medical treatments is their side effect profile.
- Medical treatments include nonsteroidal anti-inflammatory drugs (NSAIDs), progestins (ie, medroxyprogesterone), combination estrogens and progestins, synthetic androgens (ie, danazol), and gonadotropin-releasing hormone analogues with or without hormone replacement therapy.
- Surgical management can be either conservative (ie, laparoscopy with lysis of adhesions) or definitive (ie, total abdominal hysterectomy with bilateral salpingo-oophorectomy [TAH/BSO]).
- The fact that TAH/BSO relieves the symptoms of endometriosis is well established. In some cases, however, not all of the endometrial tissue implanted outside the uterus can be removed and symptoms may persist.
- Patients may require surgery involving dissection of the urinary tract, bowel, and/or rectovaginal septum.
- There is some degree of recurrence even after surgical therapy.
- Stable patients with the presumptive diagnosis of endometriosis require gynecologic referral for long-term management.
Consultations
- Obstetrician/gynecologist
Medication
Medication management beyond pain control is outside the scope of emergency medicine. Patients should have their pain controlled and be referred to a gynecologist for further management.
Medical therapy for treating endometriosis involves hormonal therapy. Progestins, combination estrogens/progestins, danazol, and gonadotropin-releasing hormone (GnRH) agonists are some of the medications used. Patients should not begin a regimen of danazol or GnRH agonists unless they are monitored by a gynecologist and have a laparoscopically confirmed diagnosis of endometriosis.
Suppression of ovulation and menses often occurs with medical management.
Hormones
These agents can make endometrial tissue become inactive and atrophic.
Medroxyprogesterone acetate (Cycrin, Provera)
Progestins stop endometrial cell proliferation, allowing organized sloughing of cells after withdrawal. Typically does not stop acute bleeding episode but produces normal bleeding episode following withdrawal.
Adult
10-20 mg PO qd continuously
Pediatric
Not established
Aminoglutethimide may decrease effects by increasing hepatic metabolism of medroxyprogesterone
Documented hypersensitivity; cerebral apoplexy; undiagnosed vaginal bleeding; thrombophlebitis; liver dysfunction
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in asthma, depression, renal or cardiac dysfunction, or thromboembolic disorders
Ethinyl estradiol and norgestimate (Ortho Tri-Cyclen, Ortho-Cyclen)
Reduces the secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary by decreasing amount of gonadotropin-releasing hormone.
Adult
28-tab package: Begin dose on first Sunday after onset of menstruation; start that Sunday if menstrual period starts on Sunday
21-tab package: 1 tab qd for 21 d followed by 7 d off medication; new course begins on 8th d after taking last tab
Continue dosing cycle if 1 period missed; pregnancy test required if 2 periods missed
Pediatric
Not established
Phenobarbital, phenytoin, paramethadione, carbamazepine, troglitazone, rifampicin, and griseofulvin induce enzymes that decrease levels of contraceptive steroids; oral anticoagulants may increase thromboembolic potential; antibiotics may alter GI flora and cause a reduction in absorption of oral contraceptives, which may reduce efficacy
Documented hypersensitivity; endometrial or hepatic cancer; thromboembolic disorders; undiagnosed vaginal bleeding; smokers >35 y; cardiovascular disease
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in patients with hepatic impairment, migraine, seizure disorders, cerebrovascular disorders, breast cancer, or thromboembolic disease
Danazol (Danocrine)
Synthetic steroid analog, derived from ethisterone, with strong antigonadotropic activity (inhibits LH and FSH) and weak androgenic action without adverse virilizing and masculinizing effects. Use of androgens might stimulate erythropoiesis and clotting efficiency. Androgens alter endometrial tissue so that it becomes inactive and atrophic.
Adult
400-600 mg/d PO divided bid/tid
Pediatric
Not established
Decreases insulin requirements and increases effects of anticoagulants; may increase carbamazepine and cyclosporine levels
Documented hypersensitivity; seizure disorders; renal or hepatic insufficiency; cardiac disease; lactation; conditions influenced by edema; undiagnosed genital bleeding; porphyria
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in renal, hepatic, or cardiac insufficiency, and seizure disorders
Leuprolide acetate (Lupron, Eligard)
Suppresses ovarian steroidogenesis by decreasing LH and FSH levels
Adult
3.5-7.5 mg/mo IM; not to exceed 6 mo without adding low-dose estrogen and progestin therapy
Pediatric
Not established
None reported
Documented hypersensitivity; undiagnosed vaginal bleeding, and spinal cord compression
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in patients with urinary tract obstruction; tumor flare and bone pain may occur; monitor patients for weakness and paresthesias
More on Endometriosis |
| Overview: Endometriosis |
| Differential Diagnoses & Workup: Endometriosis |
 Treatment & Medication: Endometriosis |
| Follow-up: Endometriosis |
| References |
| « Previous Page | Next Page » |
References
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Further Reading
Keywords
endometriosis, pelvic pain, infertility, endometrial implants, endometriosis externa, endometrioma, gynecologic disorder, gynecologic pain, retrograde menstruation, oral contraception, women's health
