Managing Endometriosis Pain With Hormonal Contraceptives

Peter Kovacs, MD, PhD


November 07, 2018


Histologically, endometriosis is a benign disease but symptoms may be so severe that despite the use of analgesics the quality of life can greatly suffer. When deep infiltrating endometriosis involves the bowels, bladder, or ureters, surgery may be the only option to avoid severe complications. Most cases are not this deeply infiltrating, however, and require treatment primarily to control the painful symptoms.

Treatments that induce hypoestrogenism and therefore interfere with the proliferation of endometrial implants are effective in this goal. In addition, medical treatments that lead to a progestin- or androgen-dominant environment are effective as well.

COCs contain both estradiol and progestins but the dominant component is the progestin. Their use is associated with estrogen-receptor downregulation and reduced proliferation. Furthermore, they lead to reduced nerve density and angiogenesis in endometriotic implants. The net effect is reduced endometriosis proliferation and potentially improved symptoms.[4]

The gold standard of diagnosis is surgery and the histopathologic exam, but treatment can be started based on radiologic findings (eg, finding of endometrioma) or symptoms alone. Although symptoms may be severe with early-stage disease as well, radiologic findings are more characteristic of advanced-stage disease. The method of determination (radiologic vs surgical) in a clinical trial therefore will likely identify patients with different stages of the disease and as a result will lead to the recruitment of heterogeneous patient populations.

GnRH analogues, progestin-only hormonal treatment, androgens, and COCs have all been effectively used to manage patients with endometriosis-related pain. COCs are usually well tolerated, are not associated with symptoms of hypoestrogenism and bleeding irregularities are uncommon, and offer contraception free of androgenic side effects. Furthermore, the cost associated even with continuous use is affordable. Therefore, the review authors concluded that COCs are a good first-line treatment option for pain related to endometriosis.


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