Medical Management Of Endometriosis Research Articles

STEROIDAL DRUGS IN ENDOMETRIOSIS.

Progestins, including medroxyprogesterone acetate (MPA), danazol and gestrinone, are used in the medical management of endometriosis. Danazol and gestrinone, by inducing progestin-like effects, closely resemble MPA in their actions on intrauterine endometrium. Ectopic endometrium, on the other hand, does not respond to these hormonal stimuli (as determined by estrogen and progestin receptor assays and 17β-hydroxysteroid dehydrogenase activity measurements), indicating that the therapeutic effects of steroidal drugs may not be entirely due to an action on the endometrium. At therapeutic doses, these drugs also prevent the midcycle elevation in gonadotropic hormone secretion and suppress ovarian activity (as evidenced by follicular arrest and low and stable estrogen and progesterone secretion). These indirect actions of progestins are probably more important than their direct actions on the endometrium in the treatment of endometriosis. These steroidal drugs also have androgenic effects, though the increase in the free androgen index caused by danazol is significantly larger than that induced by gestrinone or by MPA. In a study involving treatment with danazol (200 mg three times a day), high-dose MPA (100 mg/day) or placebo for 6 months, danazol and MPA were found to have equal clinical efficacy (as judged by relief of symptoms and disappearance of lesions). Danazol therapy, however, caused more androgenic and metabolic side-effects. Those patients who were infertile were also examined at 30 months. The cumulative pregnancy rate in these patients over the duration of the trial was danazol 33%, MPA 42% and placebo 46%, with no significant difference between treatments. Hormonal therapy delayed conception by approximately 8 months. Steroidal drugs of this type, which are useful in the treatment of both the lesion and symptoms of endometriosis, are not in general the treatment of choice for infertility associated with endometriosis.

Comparison of Different Treatment Modalities of Endometriosis in Infertile Women

Over the past three decades, medical management of endometriosis has included high-dose synthetic estrogen, diethylstilbestrol, androgens, progestins (with or without estrogen), danazol, a synthetic derivative of 17-ethinyl testosterone, and expectant management. With the exception of the last named, each of these therapies has been associated with untoward side effects, vagaries of optimal dosage, and questionable effectiveness with regard to restoration of fertility. In the present article, the authors report their experience with three modes of therapy for mild endometriosis associated with infertility and draw tentative conclusions about the management of these conditions. One hundred and forty-four patients who were investigated for infertility and found to have laparoscopically confirmed mild to moderate endometriosis (stage I or II) were included in the study. They were divided into three treatment groups: 1) no treatment (controls) (N = 56); 2) medroxyprogesterone acetate (MPA), 10 mg three times a day orally for 90 days (N = 36); and 3) danazol for 6 months (N = 52). Danazol was given in a dose of 600 mg a day orally and increased to 800 mg if breakthrough bleeding occurred or pelvic pain persisted. After therapy, patients were followed for a minimum of 30 months. During this period, other infertility factors were treated if present. There were no significant differences in mean age or duration of infertility among the three groups. The maximum cumulative pregnancy rate was reached at 30 months and was higher for the medroxyprogesterone acetate group than for the danazol or control group, but the differences were not significant. Because infertility is multifactorial, the frequency of other problems that were present and corrected, such as male factors and cervical and ovulatory disorders, were compared also. The presence of other infertility factors was not significantly different among the three treatment groups. The presence of corrected confounding factors and ovulatory disorders did not appear to influence the rate of pregnancy. Figure 1 illustrates the life-table analysis of all three treatment regimens. The cumulative pregnancy rate reached a plateau at 30 months. At that time, it was 71 per cent for the medroxyprogesterone acetate group, 46 per cent for the danazol group, and 55 per cent for the controls. The mean conception rate per month of exposure to pregnancy was 3.6 per cent for the medroxyprogesterone acetate group, 3.4 per cent for the danazol group, and 3.1 per cent for the control group. Patients with stage I disease did not differ from those with stage II disease. The rate of spontaneous abortion among the patients who became pregnant was examined also, according to treatment modality. Although the danazol and medroxyprogesterone acetate groups had lower abortion rates than controls, the difference was not significant.

Medical Management of Endometriosis

Medical Management of Endometriosis

462 Medical management of endometriosis with gestrinone: Open randomized study

462 Medical management of endometriosis with gestrinone: Open randomized study

Medical management of endometriosis.

Medical management of endometriosis.