Medical treatment of pelvic pain encompasses a selection of hormonal treatment options combined with analgesics.
Until now there is no data supporting a superiority of one medication-based treatment option over the other. Hence, it will be your attending physician and you selecting the right drug combination based on your risk factors, your preferences and the cost of the treatment. Often used treatment regimens are the combination of an estrogen-progestin contraceptive such as the pill, a patch or a vaginal ring plus an analgesic i.e. Ibuprofen or Naproxen. In order to attain pain relief the usage of adjuvant medications such as Amitriptylin is a further option. In case of contraindications for the combined oral contraceptive your physician is likely to offer you a progestin-only pill, an implant or an intrauterine device. Hormonal treatment options are contraceptive, thus are not eligible for women who are trying to conceive.
Combined Estrogen-Progestogen Contraceptives
Combination of estrogen and progestogen i.e. in the pill or the patch is an antihormonal treatment that constitutes the first line treatment for women suffering from mild or moderate endometriosis. Both cyclical and continuous-dose hormonal regimes seem to effectively reduce endometriosis related pelvic pain. The estrogen-progesteron combination suppresses the growth of uterine endometrial as wells as extra uterine endometrial tissue by stopping ovulation. Hence, inflammatory effects are lessened and symptoms are hoped to improve. In endometriosis the chosen preparation is continuously applied so that a situation of no bleeding, amenorrhea, is obtained. The use of an estrogen-progestogen preparation does not cure endometriosis but is used to alleviate pain and bleeding symptoms.
In case of contraindications for a combined therapy with estrogen-progestogen usage of a progestin-only preparation is another treatment option. A continuous application of progestins leads to a thinning and inactivity of the endometrial lining as well as the endometrial implants. Options that are often offered to patients are the continuous intake of the minipill, the intrauterine device such as the Mirena coil or Progesterone depot that is injected every three month.
While using progestogen-only preparations you may get some side effects at first, however not every woman does. These include acne, breast tenderness, weight change and headaches. Often these may stop within a few month.
In contrast to the combined pill the progestogen-only pill is a form of hormonal treatment only containing progestogen. It is taken every day without a break. If you want to stop due to reasons such as intolerable side effects or a new wish to conceive you can stop taking the progestogen-only pill at any time. Soon after your fertility will be the same as if you had never taken it.
Intrauterine device with progestin (e.g. Mirena coil)
The intrauterine device or also called the coil is a small plastic T-shaped device with small plastic or nylon strings at one end that is inserted into the uterus by your GP and can stay there for up to five years. The insertion can be performed during a slightly longer outpatient appointment but does not require any anaesthesia. After being inserted only the strings are seen at the cervical opening. Once put in the device steadily releases low dose of progestogen, which acts locally to stop the buildupof the lining of the uterus, thickens the mucus and occasionally prevents ovulation. As the coil sits directly inside the uterus a smaller hormone dose is needed and most of the hormones stay inside the womb with only a small percentage being absorbed intothe rest of the body.
Removal of the device can be performed whenever desired but should be performed by a qualified practitioner. Fertility is not being impaired after having used the coil.
DEPOT PROGESTERONE (E.G. DEPOT-PROVERA)
The Depot Progesterone usually contains Medroxyprogesterone (Depot-Provera) that is injected into the muscle of your bottom every 12 weeks. It acts by systemically releasing progesterone from the depot. After 12 weeks the effects start to wear off however it may take a longer time until the Progesterone completely left the body and you start ovulating and menstruating again. Thus, it can take a while (up to a year) to return to normal fertility. Once the effect has worn off however fertility will be the same as if the Depot Progesterone has never been used. Due to the length of time that it takes for the drug to leave the body Depot Progesterone is usually not recommended if you wish to conceive in near future.
If you decide for the progestogen implant a small implant is subcutaneously injected on the inner side of the upper arm which steadily releases progestogen. It must be replaced or removed after three to five years, depending on the implant used. It can be taken out via a small incision whenever wished and fertility is regained few days after removal.
Gonadotropin-releasing hormone (GnRH) agonists
As a second-line therapy GnRH agonists might be proposed by your attending physician. These are injected every month. Gonadotropin releasing hormones (GnRH) are naturally ocurring hormones that are released in a pulsatile manner from a part of your brain called the hypothalamus. They are in charge of controlling the ovarian release of hormones and hence control the menstrual cycle. GnRH agonists are modified versions which are continuously used for longer than two weeks stop the production of estrogen in the ovaries and essentially place the body in an artificial menopausal state. As the endometrium depends on hormones i.e. estrogens, progestogens and GnRH for growth and differentiation lack of the mentioned causes it as well as the endometrial implants to become thinner and inactive.
If you have GnRH injections for a longer period of time, usually after six month, or due to individual risk factors your attending physician will probably recommend an “add-back” hormone replacement therapy (HRT) in order to reduce or prevent menopausal side effects of these drugs. It is thought that there is a threshold of estrogen amount to activate endometriotic lesions. In HRT only a small amount of estrogens is given- enough to relieve or prevent symptoms such as hot flashes or loss of bone densitiy and below the threshold of activating endometrium and endometriotic lesions. The most commonly used GnRH agonists in the treatment of endometriosis are Leuprorelin (Prostap), Goserelin (Zoladex), Nafarelin (Synarel), Buserelin (Suprecur), Triptorelin (Decapeptyl).