Medical Management of Endometriosis

Women with pelvic pain, suspected endometriosis, and no otherindication for surgical treatment can be managed effectivelywith empiric medical treatment without es tablishing a surgicaldiagnosis. ۳۹۵ Initial empiric medical therapy usually involvestreatment with NSAIDs and oral contraceptives (OCs;combined or proges tin only). If treatment with NSAIDs andOCs does not significantly improve pain, second- and thirdlinemedical therapies or GnRH agonis t and Antagonis t. Traditionalmedical therapies for endometriosis have been basedon Sampson’s theory of retrograde mens truation and implantationand on the simple premise that ectopic endometrium maybe expected to respond to treatment in much the same way asnormal eutopic endometrium. Consequently, the objectives oftreatment have been to reduce or eliminate cyclic mens truation,thereby decreasing peritoneal seeding and the likelihoodthat new implants will develop, and to suppress the growth andactivity of the endometrium, anticipating that the same wouldoccur in the endometriotic tissue derived from it. Interventionsthat reduce ovarian es tradiol production are the mos t reliableways to cause atrophy of endometriotic lesions and the mos teffective treatment for pain. These simple operational conceptshave shaped medical treatments for endometriosis for decades,but our growing unders tanding of the pathogenesis of endometriosisat the molecular level is now beginning to sugges t newtreatment s trategies aimed at the mechanisms of disease.Es tablished medical therapies for the treatment of pain associatedwith endometriosis include es trogen-proges tin contraceptives,proges tins, GnRH analogues and GnRH Antagonis t. Typically,OCs are the firs t line of therapy with GnRH antagonis tsbecoming the optimal second-line therapy in those who fail OCtreatment or have troubling proges tin-related side effects. Treatmentdecisions mus t be individualized, after carefully consideringthe severity of symptoms, the extent of disease, the desire for future pregnancy, age, side effects, and cos ts. Research isongoing for the development of new therapeutic agents.