CLINICAL ACTIONS:

• Definitive diagnosis is surgical and made on histology of lesions removed.  Lesions can be black powder-burn, red or white
  • Imaging studies are useful only in the presence of a pelvic/adnexal mass
  • Transvaginal ultrasound is the technique of choice in differentiating an endometrioma from other adnexal masses, and in detecting deeply infiltrating endometriosis of the rectum or rectovaginal septum
  • MRI can be used when ultrasound results are equivocal
• American Society for Reproductive Medicine (ASRM) classification system is most commonly used, but is not a good correlate with fertility or symptoms
• Excision of endometriomas can improve pregnancy rates
• Drainage and ablation is less effective

SYNOPSIS:

Endometriosis is a chronic condition. Clinical manifestations vary and are not good predictors of the severity of the disease. Dysmenorrhea, chronic pain, dyspareunia, uterosacral ligament nodularity, and adnexal masses are among the common presentations. Treatment is aimed at optimizing pregnancy rates and minimizing symptoms; definitive treatment remains removal of the ovaries, fallopian tubes and uterus.

KEY POINTS:

• Pain associated with endometriosis can be reduced with use of:
  • Progestins, combined oral contraceptives (OCs), nonsteroidal anti-inflammatory drugs, gonadotropin-releasing hormone (GnRH) agonists, danazol
  • Extended cycle OCs or continuous OCs can be used to limit dysmenorrhea
• Nongynecologic causes of pelvic pain such as irritable bowel syndrome, interstitial cystitis and urinary tract pathology should be ruled out with appropriate testing and referral
• The levonorgestrel intrauterine device is effective in reducing pelvic pain related to endometriosis
• GnRH agonists are FDA approved for up to 12 months
  • ‘Add back’ therapy reduces side effects and bone loss and may include (1) progestins alone, (2) progestins and bisphosphonates, or (3) low dose progestins and estrogens
  • There is no difference between GnRH agonists and other medical treatments for endometriosis based on a recent Cochrane review, so should not be used as a primary treatment
    • GnRH agonists are, however, first line for extrapelvic endometriosis treatment
• Elagolix is FDA approved for up to 6 months
  • Normal liver function or mild hepatic impairment: 150 mg once daily for up to 24 months or 200 mg twice daily
  • Moderate hepatic impairment: 150 mg once daily for up to 6 months
  • Contraindications: Pregnancy | Known osteoporosis | Severe hepatic impairment | Strong organic anion transporting polypeptide (OATP) 1B1 inhibitors
  • Potential for Reduced Efficacy with Estrogen-Containing Contraceptives: Use non-hormonal contraception during treatment and for one week after discontinuing elagolix
  • Note: For further warnings & precautions and adverse reactions see FDA HIGHLIGHTS OF PRESCRIBING INFORMATION in ‘Learn More – Primary Sources’ below
• Aromatase inhibitors such as letrozole or anastrozole appear promising in observational trials but await more data
• Patients undergoing surgery for removal of endometriosis should be counseled that they have about a 36% chance of requiring further surgery
• Hormone therapy with estrogen is not contraindicated after hysterectomy with bilateral salpingo-oophorectomy for endometriosis
• Diagnosis Codes: ICD-10-CM: N80.0-N80.9, depending on location of endometriosis

Learn More – Primary Sources:

ACOG Practice Bulletin No. 114: Management of Endometriosis 

ASRM: Treatment of Pelvic Pain Associated with Endometriosis: A Committee Opinion

Optimal Management of Endometriosis and Pain

Endometriosis: Where Are We and Where Are We Going?

Gastrointestinal and Urinary Tract Endometriosis: A Review on the Commonest Locations of Extrapelvic Endometriosis

Drugs@FDA: FDA Approved Drug Products: Orilissa 

FDA: HIGHLIGHTS OF PRESCRIBING INFORMATION for ORILISSA

Related ObG Topics:

ACOG Guidance on Evaluation and Management of Endometriosis and Dysmenorrhea in Adolescents

Comparing IUD vs Implant for the Management of Endometriosis

Infertility Evaluation: Who, When and How

Does the Oral GnRH Antagonist Elagolix Improve Endometriosis-Associated Pain?