Medication Summary
The goals of pharmacotherapy are to obtain atrophy of the endometrium, reduce morbidity, and prevent complications.
Gonadotropins
Class Summary
These agents stimulate the release of luteinizing hormone and follicle-stimulating hormone from the anterior pituitary. In large doses, they can cause down-regulation of receptors in the pituitary gland, which, in turn, decreases secretion of luteinizing hormone and follicle-stimulating hormone. These agents produce more consistent endometrial thinning. Pretreatment with GnRH agonists or danazol before resectoscopic endometrial ablation (REA) results in higher amenorrhea rates at 12 months, shorter procedures, greater reported ease of surgery, and lower postoperative dysmenorrhea rates.
Goserelin (Zoladex)
Goserelin suppresses ovarian and testicular steroidogenesis by decreasing luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels. This agent is administered monthly as a subcutaneous (SC) implant in the upper abdominal wall; it is otherwise similar to the drugs in this class.
Leuprolide (Lupron, Lupron Depot, Eligard)
Leuprolide suppresses ovarian and testicular steroidogenesis by decreasing luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels. This agent is available in a daily subcutaneous (SC) dosing regimen and the much more convenient monthly intramuscular (IM) depo formulation. A 3-month depo dosing formulation is also available, but experience with its use for endometriosis is limited.
Nafarelin (Synarel)
Nafarelin is an analogue of gonadotropin-releasing hormone (GnRH) that is approximately 200 times more potent than natural endogenous GnRH. With long-term administration, this agent suppresses gonadotrope responsiveness to endogenous GnRH, thereby reducing the secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which, in turn, reduces ovarian and testicular steroid production.
Nafarelin is available as a nasal solution (2 mg/mL). Administration of this agent is delivered via a nasal spray, which requires twice daily (bid) dosing; it is otherwise similar to the other drugs in this category.
Gonadorelin
Gonadotropin-releasing hormone (GnRH) agonists have been used to pretreat the endometrium and obtain atrophy.
Androgens
Class Summary
Agents from this class may suppress pituitary secretion of follicle-stimulating hormone and luteinizing hormone.
Danazol
Danazol causes atrophy of normal and ectopic endometrial tissue by suppressing pituitary output of luteinizing hormone and follicle-stimulating hormone. Pretreatment with danazol or GnRH agonists before resectoscopic endometrial ablation (REA) results in higher amenorrhea rates at 12 months, shorter procedures, greater reported ease of surgery, and lower postoperative dysmenorrhea rates.
Progestins
Class Summary
These agents may induce endometrial thinning by inhibiting the secretion of pituitary gonadotropins.
Medroxyprogesterone (Depo-Provera, Provera)
Progestins stop endometrial cell proliferation, allowing organized sloughing of cells after withdrawal. These agents typically do not stop acute bleeding episodes, but they produce normal bleeding episodes following withdrawal.
Medroxyprogesterone is a common progestin available in both an oral (PO) and an intramuscular (IM) depo form. The efficacy and adverse effects of this drug are similar to those of norethindrone.
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Volume contrast imaging showing sagittal view of the uterus and endometrium (left) and coronal view of the endometrium with an endometrial polyp in the fundal region (arrow). Images courtesy of Noah Lazebnik, MD.
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The orthogonal views (sagittal, axial and coronal), as well as the rendered 3D image of the endometrium, taken by vaginal 3-D ultrasound transducer. Images courtesy of Noah Lazebnik, MD.
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ThermaChoice uterine balloon device.
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HerOption cryoablation device.
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Hydrothermal endometrial ablation (HTA) device.
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NovaSure bipolar radio frequency device.
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Microsulis Endometrial Ablation (MEA) microwave device.
Tables
Method |
Sounded Uterine Length |
Cervical Dilation |
Time |
Pretreatment |
|
|
Min |
Max |
(cm) |
(min) |
|
Thermal balloon |
4 |
10 |
5 |
8 |
Suction curettage |
Cryotherapy |
n/a |
10 |
5 |
14 |
Yes |
Hydrothermablation |
4 |
10.5 |
8 |
10 |
Yes |
Microwave |
6 |
14 |
8 |
3.5 |
Yes |
Bipolar energy |
6 |
10 |
8.5 |
1.5 |
No |
