Evaluation and Treatment of Endometriosis

SYNOPSIS:

Endometriosis is a chronic condition that results in infertility and chronic pain. 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:

Symptoms

  • Dysmenorrhea
  • Chronic pelvic pain
  • Dyspareunia
  • Uterosacral ligament nodularity
  • Adnexal masses
  • Bowel and bladder symptoms, such as dyschezia, hematochezia, hematuria, dysuria
  • Symptoms do not correlate with severity of disease

Diagnosis

  • 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

Treatment

Medical Management

  • 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 and reduce recurrence of endometriomas
  • 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
    • A 3 month course can be empirically started after treatment failure with OCs and NSAIDs
    • ‘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 (GnRH antagonist) is FDA approved for management of moderate to severe pain associated with endometriosis
    • 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 to elagolix 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

Surgical Management

  • Excision of endometriomas can improve pregnancy rates; drainage and ablation of cyst is less effective
  • Patients undergoing surgery for removal of endometriosis should be counseled that they have about a 36% chance of requiring further surgery
  • In women who do not desire future fertility, definitive therapy is hysterectomy, bilateral salpingo-oopherectomy
  • 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

FDA: HIGHLIGHTS OF PRESCRIBING INFORMATION for ORILISSA