What is the role of estrogen or progestin add-back therapy in the treatment of endometriosis?

Updated: May 10, 2021
  • Author: G Willy Davila, MD; Chief Editor: Michel E Rivlin, MD  more...
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Much interest has been shown in whether estrogen/progestin "add-back" therapy should be instituted to prevent osteoporosis and hypoestrogenic symptoms. Hormone replacement therapy preparations, progestins, tibolone maleate, and bisphosphonates have all been shown to be effective. [80, 81, 82, 83] Add-back therapy has been shown to prevent loss in bone density and to relieve vasomotor symptoms without reducing the efficacy of GnRH regimens. GnRH agonists have been used for 12 months with norethindrone add-back therapy with good results. [84]

A clinical trial has shown that a 3-month empiric course of GnRH, based on a diagnostic algorithm without definitive laparoscopic diagnosis, is efficacious. [85] However, long-term effects of GnRH analogues on bone density in this population remain unproven. Therefore, add-back therapy remains the standard of care while the patient is on GnRH treatment. Also, empiric treatment without a firm diagnosis could result in unnecessary treatment in patients with chronic pelvic pain, whose condition could be due to other causes. In Ling's study, 13% of subjects were shown to not have endometriosis. [85]

GnRH therapy has also been proven to relieve the pain and bleeding associated with extrapelvic distant endometriosis. [86]

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