Endometriosis: Hormonal Treatment Overview

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There is no surgical cure for endometriosis, and if it is untreated it will grow, causing pain and lowering your chances of being able to become pregnant in the future. This is why you need to take hormonal medications. Treatment is aimed at controlling pain and preventing the endometriosis from getting worse. This guide was created to help you understand the different choices of hormonal treatment for endometriosis, as well as the benefits and possible side effects that are most commonly reported.

How do I know if hormone treatment is right for me?

Most young women can take hormone medicine, however, if you have certain medical conditions (such as a history of blood clots, high blood pressure, certain kinds of heart disease, hepatitis, severe migraines with visual changes or numbness over parts of your body, or if you smoke), certain hormonal therapies may not be an option for you. Be sure to tell your gynecologist if you have migraine headaches with loss of vision, flashing lights, numbness/tingling, or loss of speech. Also, it is very important to tell your gynecologist if anyone in your family has ever had a blood clot or stroke.

How does hormonal treatment work?

Hormonal treatment works by temporarily turning off your ovaries so you don’t ovulate (make eggs). When you don’t ovulate, you don’t have regular periods. When you are prescribed hormonal treatment continuously, you will rarely have periods or not have them at all. Since bleeding can cause pain for anyone with endometriosis, stopping your period will usually improve your pain. Hormonal treatment includes the Pill, vaginal ring, an injection (once every 3 months), an IUD (which is placed in the uterus) or a hormonal patch.

Hormonal treatment with combined estrogen and progestin:

Combined oral contraceptive pills (OCPs): contain the hormones estrogen and progestin. The goal of the treatment is to stop your periods and pain caused from endo. Young women with endometriosis will take these pills in a continuous fashion, meaning skipping the placebo or sugar pills at the end of the pack so that a period does not occur.

The vaginal ring: The vaginal ring is a small, thin, flexible rubber ring that fits inside the vagina. Once in place it releases a combination of estrogen and progestin. If you choose this method of hormonal treatment for your endo, you would insert the ring and leave it in place for 3 weeks. You would then take it out and replace it with a new one right away. (If you are sexually active, neither you nor your partner will be able to feel the ring when it is inserted properly.)

The patch: The patch is a small, tan piece of plastic that looks like a bandage. It also release a combination of estrogen and progestin, and you only need to change your patch once a week. The patch is made to stay in place even when you shower or go swimming or sweat.

Benefits:

  • Combined estrogen and progestin hormonal therapy may decrease or stop endo pain.
  • Most girls will only have 0–4 periods a year.
  • Some young women prefer using the vaginal ring or patch because they don’t need to remember to take it every day.

Possible side effects:

  • Spotting or breakthrough bleeding is common especially if you are skipping your periods, but the spotting should decrease over time.
  • Some girls may have heavier bleeding or a regular period.
  • Breast tenderness, mood swings, headaches, nausea, cramps, bloating, and/or weight gain.
  • There is some concern that the patch may release a higher dose of hormones than the pill, which can increase the risk of blood clots and/or stroke.
  • Some girls who use the hormone patch may have skin irritation where the patch is worn.
  • Some girls who use the vaginal ring may have vaginal irritation, but infection is not an increased risk.
  • Some girls may not have relief from their endometriosis pain.

Progesterone-only hormonal treatment:

Norethindrone: Norethindrone 0.35mg daily is a form of birth control that does not contain estrogen.

Norethindrone acetate: Aygestin® (Norethindrone acetate) is a pill that contains only progestin. The dosage is 5–10mg per day. This is a strong progestin, however it is not an approved form of contraception and may require a co-pay at the pharmacy.

Medroxyprogesterone Acetate (Depo–Provera®): Medroxyprogesterone acetate is another type of medication that only contains the hormone progesterone. It is an injection that is given once every 3 months by a nurse or your primary health care provider. Medroxyprogesterone acetate is used to temporarily stop your menstrual cycle.

IUD or Mirena®: is a type of intrauterine device that contains progestin. Sometimes the IUD is not strong enough at suppressing all endometriosis symptoms because it works locally inside the uterus, so an additional pill may be prescribed to decrease symptoms.

Implants: Hormonal implants such as Nexplanon® come in the shape of a tiny tube that is placed under the skin in the upper arm. The implant prevents pregnancy and reduces the size of lesions caused from endometriosis. It is effective for 3 years. The implant is about the size of a toothpick and made of a flexible plastic that contains a type of progestin hormone medicine called etonogestrel.

Benefits:

  • Progesterone-only hormone therapy can be effective in treating symptoms of endometriosis.
  • The Mirena® IUD lasts up to 5 years.
  • The IUD plus oral contraceptive pills can lessen bleeding and pain from endo.
  • The Nexplanon® Implant lasts for 3 years.

Possible side effects:

  • Spotting or breakthrough bleeding can last for a few days until your body gets used to the medicine, or as long as you are taking it
  • Bleeding or a regular period
  • Breast tenderness, nausea, bloating, weight gain, and/or hair thinning
  • Headaches, mood swings including depression, nervousness
  • Bone density loss and increased risk of osteoporosis (thinning of your bones) when taken for a long time
  • Some girls may not have relief from their endometriosis pain

Hormonal treatment with GnRH agonists (gonadotropin releasing hormone agonists) and Add–Back and GnRH antagonist:

A GnRH agonist or antagonist is typically prescribed when other hormonal medications do not work in relieving moderate to severe endo pain. The goal of these medications is to stop the endometriosis from growing.

GnRH agonists/antagonist work by temporarily turning off your pituitary gland, which stops your ovaries from making estrogen and progesterone (so you won’t have a period). Since all of these medications lower estrogen levels, the possible side effects for all of the medicines in this group are the same symptoms that women often have during menopause. To decrease these symptoms, your gynecologist should start on you something called add-back therapy. Add-back therapy is a small amount of progestin, or a combination of estrogen and progestin, that is just enough to treat menopausal symptoms but not enough to cause endometriosis symptoms.

Treatment with GnRH Antagonist: Elgonix (Orlissa ™) is the first GnRH antagonist developed to treat endometriosis. It was approved by the US Federal Food and Drug Administration (FDA) in July,2018. It is a daily pill taken by mouth and it is available in two doses. Benefits and possible side effects are similar to Lupron® and Synarel®.

Leuprolide Acetate (Lupron–Depot®): Leuprolide acetate is one type of GnRH agonist that is given as an intramuscular (in the muscle) injection (shot). It can be given either once a month or once every 3 months. Our GYN team prefers that you get the injection once every 3 months so you don’t have to come in for appointments every month. Please make sure that the shot comes in the 3-month form (blue box).

Nafarelin Acetate: Nafarelin acetate (Synarel®) is another type of GnRH agonist that comes in the form of a nasal spray. Synarel is started with one puff in one nostril in the morning, then another puff in the OTHER nostril at nighttime. This dosage may be adjusted depending on your symptoms.

Benefits:

  • Low levels of estrogen cause your period to stop and endometriosis from growing.
  • Low levels of estrogen stop endo from growing so your fertility is preserved.

Possible side effects:

  • Bone density loss and higher risk of osteoporosis (thinning of your bones), especially when taken without a small amount of hormones (add–back therapy).
  • Side effects may include hot flashes, mood swings, vaginal dryness, bone and joint aches, hair loss, low libido (lack of interest in sex), and possible short–term memory loss.
  • In many cases, young women may be able to stay on this treatment longer than six months as long as their bone density is checked and is normal.
  • Some young women may not have relief from their endometriosis pain.
Remember, all medicines affect each person differently. It usually takes about 2–3 months or cycles to see an improvement in symptoms and for your body to get used to any new medicine. Side effects will go away soon after the medication is stopped and your menstrual cycle returns. Deciding what treatment is best for you may take some time. Talk to your GYN team about any concerns or questions you might have. In the meantime, you can help your body feel better by eating well and getting exercise and sleeping 8-9 hours every night.