THE MEDICAL TREATMENT OF MILD ENDOMETRIOSIS

Minor degrees of endometriosis have often been regarded as being of no import and hence remain untreated, but a study of the natural history of endometriosis has demonstrated that 47% (95% confidence limits, 23-71%) of patients (n=35) given placebo in a double-blind, randomized controlled trial showed progression of the disease when assessed before and after treatment by laparoscopy. The active agent, the progestogen gestrinone, was given at a dose of 2.5 mg twice weekly and resulted in an improvement of the disease (p <0.004). Furthermore, follow-up over 12 months showed no significant difference between those patients treated with active agent or placebo, and none between those with persistent disease and those in whom it had been obliterated. These data suggest that a diagnosis of mild endometriosis should be followed by treatment to prevent progressive disease, but that the treatment does not influence subsequent fertility. They indicate that expectant treatment has no place and that even if fertility is not an immediate requirement, active treatment should be instituted, and that the new gestogen, gestrinone is efficacious. Other treatments, such as danazol or luteinizing hormone releasing hormone (LHRH) agonists, or the older contraceptive or pseudopregnancy regimens, must be set against spontaneous improvement (in 5 of 17 patients i.e. 29%) or elimination (in 4 of 17 patients i.e. 24%) in the placebo group. Infertile patients with mild endometriosis have disorders of follicular and luteal function, and in vitro fertilization suggests a reduced fertilization rate. Nevertheless, these patients require active treatment if these problems are not to be compounded by adhesions, possibly leading to ovarian enclosure, that would further reduce the untreated cumulative conception rate.