COMMENTARY

Managing Endometriosis Pain With Hormonal Contraceptives

Peter Kovacs, MD, PhD

Disclosures

November 07, 2018

Endometriosis-Related Pain

Endometriosis is a benign disease that is diagnosed when endometrial glands and stroma can be found in extrauterine locations. Most commonly, endometriosis involves the fallopian tubes, ovaries, and cul-de-sac, but it may be found in distant locations as well. The stage of the disease is based on its spread in the pelvis and the density of associated adhesions. Endometriosis is hormone sensitive and cycles like the endometrium. The adhesions that usually accompany endometriosis are partly responsible for the painful symptoms because they can immobilize various pelvic organs.[1]

Pain is the most common symptom of the disease, and pain severity does not necessarily correlate with the stage of the disease. Dysmenorrhea, dyspareunia, and chronic pelvic pain are the most common forms taken by this pain. Surgical or medical treatments can be offered to manage them. Surgery offers temporary relief but eventually the disease will recur. The various medical treatment options are characterized by different risk-benefit and side effect profiles. Combined oral contraceptives (COCs) are commonly prescribed to women affected by endometriosis.[2] A recent systematic review[3] evaluated the evidence about the effect of COCs on endometriosis-related pain.

Review Summary

The review comprised nine randomized controlled trials and nine observational studies. Most studies required a surgical diagnosis of endometriosis but some allowed radiologic diagnosis. Pain is typically assessed using a visual analogue scale, but the methods differed among the studies.

The following observations were made:

  • Compared with placebo, COCs offered a threefold reduction in dysmenorrhea. COCs in these studies did not have a significant impact on nonmenstrual pain

  • Both gonadotropin-releasing hormone agonists (GnRHa) and COCs (cyclic or continuous) resulted in significant reduction of menstrual and nonmenstrual pelvic pain. The magnitude of impact was mostly similar in the different studies, although some reported greater improvement with GnRHa

  • Both COCs and progestin (cyproterone acetate) resulted in significant and similar reductions in dysmenorrhea, dyspareunia, and chronic pelvic pain

  • When cyclic and continuous COC use were compared, both were found to be effective in the management of pain but the effect was seen earlier with continuous use

  • The review found improved quality of life with COCs, progestins, and GnRHa as well

The review authors concluded that COCs (cyclic or continuous use), a low-cost treatment option, are effective for the treatment of cyclic or chronic pain related to endometriosis.

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