What are the options treating endometriosis?

There are basically three approaches to the treatment of endometriosis:

• Expectant care. (Treatments involve relieving symptoms.)
  
• Hormonal therapy. (Aimed at reducing endometrial implants.)
  
• Surgery. (Aimed at reducing endometrial implants, restoring fertility, or possible a cure.)

The choice depends on a number of factors like

• symptoms
  
• age
  
• whether fertility is a factor
  
• the severity of the disease.

EXPECTANT CARE

Expectant care is a initial choice for the following:

• Women with mild pain .
  
• Women approaching menopause.

Early diagnosis and treatment in young women without symptoms might prevent some cases of infertility later on.

HORMONAL THERAPY

Hormone therapies are used to mimic states in which ovulation does not occur (such as pregnancy or menopause) or to directly block ovulation.

Such agents include oral contraceptives, progestins, GnRH agonists, and danazol. They can by very effective in relieving symptoms of endometriosis.

Some of these drugs may also be used after surgery to help prevent recurrence of endometriosis.

But there are drawbacks:

• None of these agents can cure the problem. Symptoms recur in about half of patients within five years of treatment.
  
• They do not improve fertility rates.
  
• Side effects of these drugs can be distressing. There is a high dropout rate with the use of nearly all these hormonal treatments.
  
• Women who are taking GnRH agonists, danazol, or similar agents should use non-hormonal birth control methods (such as the diaphragm, cervical cap, or condoms) because these drugs can increase the risk for birth defects.

[ For specific descriptions of these drugs, see What is the Hormonal Therapy for Endometriosis?]

SURGERY

Surgery is an option for the following women:

• Women with severe pain that does not respond to watchful waiting and medical treatment.
  
• Women who want to become pregnant and endometriosis is most likely the contributor to infertility.

There are two basic surgical approaches for endometriosis:

• CONSERVATIVE SURGERY (LAPAROSCOPY OR LAPAROTOMY).
  
  Conservative surgery uses laparotomy or laparoscopy to remove the endometriotic implants without removing any other reproductive organs.
  
  It is a good option for women who wish to become pregnant or who cannot tolerate hormone therapy.
  
  In fact, most experts believe that laparoscopy surgery should be the treatment of choice for women with endometriosis.
  
  Endometriosis often recurs after conservative surgery,. Recurrence rates at two years range from 2% to 47%. The risk for recurrence or residual pain after any procedure increases with the severity of the condition, particularly if endometriosis has affected areas outside the uterus.
  
  [ For more details See What Is Conservative Surgery for Endometriosis?]
  
  
• RADICAL SURGERY (HYSTERECTOMY)
  
  Hysterectomy (removal of the uterus) with removal of ovaries (oophorectomy) along with all endometrial implants is the only potential cure for endometriosis.
  
  [For more details See What Is Radical Surgery (Hysterectomy) for Endometriosis?]

In choosing between hysterectomy (with or without oophorectomy) and conservative surgeries, age and the desire for children are important factors.

Once careful instruction is given for all the risks and benefits of the different surgical options, the physician must then respect any decision a patient makes to retain as much of her reproductive system as she wants, even if she is past menopause.

Both the patient and the physician should also be clear about the possibility of changing procedures once the operation has begun, depending on what the surgeon may observe. For example, the surgeon may find abnormalities that require more extensive surgery.

Much of the success of any procedure relies on the experience of the surgeon. A woman should always ask for a doctor's track record, or the number of times he or she has performed the procedure in question. The more, the better.

TREATING INFERTILITY IN PATIENTS WITH ENDOMETRIOSIS

For women with severe endometriosis who want to become pregnant, conservative surgery (typically laparoscopy) is the appropriate approach for restoring fertility.

Hormonal therapies, such as GnRH agonist or progestins, used to treat endometriosis itself have no affect on fertility.

Of interest, however, was a 2002 study suggesting that the use of the GnRH agonists after surgery helped improve conception rates in women who subsequently undergo assisted reproductive techniques (ART), such as in vitro fertilization (IVF).

In any case, ART or hyperstimulation of the ovary using fertility drugs to produce eggs are the standard fertility treatments available to women if surgery fails.