Endometriosis and Your Fertility
Understanding the condition and its treatment
Medical Therapies for Endometriosis
Before discussing any form of medical therapy, it is important to stress that there is no medical therapy that cures endometriosis. Medical therapy offers ways of temporarily suppressing the process only, not of curing it.
Endometrial implants depend on cyclic hormonal function. All medical therapies are aimed at disrupting cyclic hormone production and creating a state in which the hormones are constant from day to day. When estrogen and progesterone remain steady over a prolonged period of time, endometriosis typically does not progress, and may even regress. There are two normal physiological states in a woman’s life during which her hormones are essentially constant from day to day—pregnancy and menopause. Medical therapies aim to simulate one of these states.
In the majority of women, endometriosis improves during pregnancy. During pregnancy, ovulation stops and relatively constant, high levels of estrogen and progesterone are present. Using birth control pills can simulate these high constant levels of hormones, or create a state of “pseudo-pregnancy.”
To bring on this pseudo-pregnancy, the pill must be taken continuously. In other words, a pill is taken every day without ever stopping for a week or without taking the “sugar pills” at the end of the pack, as you would do for contraception. Thus, no periods will occur because a hormonally active pill is being taken every day, and a steady hormone state is achieved. For women who can take the pill, this is a perfectly safe way to do so. Because of the balance of the hormones in the pill, the lining of the uterus does not build up while on continuous therapy, and if anything, it actually thins out. There is no need to have a period each month while on the pill, and having one will probably render the pill far less effective against endometriosis because of the bleeding and resulting changes in the endometrial implants.
There are basically two types of medications available for creating a state of pseudo-menopause. The first of these is danocrine (Danazol). This is an altered male hormone. When taken in adequate doses, it suppresses the ovaries so that they temporarily stop functioning. This combination of decreased female hormone levels and increased male hormone levels is what makes danocrine effective in suppressing endometriosis.
Danocrine has been around for years and for a long time was the most commonly used form of medical suppression of endometriosis. It does, however, have many unpleasant side effects, including menopausal symptoms such as hot flashes and vaginal dryness. In addition, side effects from its being a derivative of a male hormone, such as weight gain, increased muscle mass, increased hair growth, and muscle cramps, limit the acceptability of danocrine. With the availability of the GnRH agonists (see below), danocrine is not widely used to treat endometriosis at this time.
The GnRH agonists are a class of medication that can temporarily suppress the pituitary gland’s production of luteinizing hormone (LH) and follicle stimulating hormone (FSH). If the pituitary does not produce LH and FSH, the ovaries receive no stimulation and therefore stop producing hormones. Thus, once again, a temporary state of menopause is achieved.
The most commonly used form of this therapy is the depo, or long-acting, form of leuprolide acetate, known as Depo-Lupron. An injection of this medication given once a month results in very effective suppression of the ovaries. The major side effects associated with this medication are menopause-related ones, specifically hot flashes and vaginal dryness. In some women, these side effects may be severe. Although it may slightly limit the overall effectiveness of the therapy, small doses of estrogen may be given along with the Depo-Lupron. That way the side effects may be eliminated without significantly compromising the effectiveness of the treatment, making this therapy very tolerable for most individuals.
Precautions in Using Suppressive Therapies
While on suppressive therapies, particularly those that induce pseudo-menopause, it is important to take a good multivitamin and calcium supplement. The lack of estrogen in these therapies can lead to development of at least a small amount of osteoporosis, or thinning of the bones. Calcium and vitamins help minimize bone loss; however, because of the risk of osteoporosis and other menopause-related side effects, the length of time that these therapies may be used is limited. Circumstances may dictate special considerations for some individuals, but six months of therapy is usually considered maximal.
All forms of suppressive therapy must be viewed as exactly that—a means of suppressing the endometriosis. In the vast majority of cases, endometriosis will not progress while on this therapy. In most cases it actually improves. Upon stopping the therapy, normal menstrual function resumes and the endometrial implants, which had been suppressed, also begin to function and respond to the cyclic hormone changes. Sometimes within a relatively brief time, the endometriosis is right back where it was before the treatment was begun. Suppressive therapies should be viewed only as ways of buying time.
For example, if you know you have endometriosis and want to get pregnant, but for one reason or another must postpone your attempts to do so for another six months, then suppressive therapy may be a great idea. There is no data to suggest, however, that medical therapy results in improved chances of conceiving. To repeat: Medical suppressive therapy is a good way to buy some time during which the endometriosis will not get worse, and it may help any pain you are having, but it is not a good way to improve your chances of getting pregnant.
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