Recent Trends in Medical Management of Endometriosis

Endometriosis affects about 10 percent women in the reproductive age group globally and approximately 42 million in India. Managing the patient's pain symptoms associated with endometriosis appears to be the cornerstone in endometriosis disease management. The ideal medical treatment in endometriosis would be suppressing estradiol enough to alleviate symptoms of endometriosis but maintain sufficient levels to mitigate hypoestrogenic side effects. NSAIDs are generally prescribed for the initial management of pain symptoms in endometriosis along with hormonal agents like progestogens or combined oral contraceptive pills (COCPs). Injectable depot gonadotropin-releasing hormone (GnRH) agonists such as leuprolide acetate and letrozole are effective as second-line agents in the management of endometriosis-associated pain. Dienogest is a 19-nortestosterone derivative which has a high specificity for progesterone receptors and improves endometriosis-related symptoms and the overall quality of life. Dydrogesterone is quite effective in the treatment of endometriosis-associated pelvic pain without causing suppression of ovulation. GnRH agonists and GnRH antagonists both have been used in the treatment of endometriosis. Elagolix a first oral, non-peptide gonadotropin-releasing antagonist for the management of moderate to severe pain associated with endometriosis is successfully used. Aromatase inhibitors are used as second-line drugs in the management of endometriosis-associated pelvic pain. They prevent the conversion of steroid precursors to estrogens, both at the periphery and at the ovarian level. Tamoxifen, raloxifene and bacidoxifen have an anti-proliferative effect and regress the endometriotic implants. Mifepristone (progesterone receptor antagonist) and Ulipristal acetate (SPRM) have been used for medical management of endometriosis. LNG-IUS is emerging as a good option for patients with endometriosis who are not desirous of conception. Hormonal management is one of the effective management options in endometriosis. One has to be mindful of molecule-specific adverse effects while prescribing drugs.