Herbert F Gretz III MD

Endometriosis is one of the most common gynecological disorders. While it is more common for women in their 20s and 30s to have the disease, endometriosis can affect women at any time during their childbearing years. In fact, it is estimated that 5.5 million women in North America are affected by endometriosis.

What is endometriosis?

Endometriosis occurs when endometrial tissue, the tissue that lines the uterus and is shed during menstruation, grows outside of the uterus—on the ovaries, fallopian tubes, ligaments supporting the uterus, and other areas in the pelvic cavity. Endometriosis can also appear in a woman's bladder, bowel, vagina, or other places in her body.

Like the lining of the uterus, these areas of endometrial tissue respond to the hormones of the menstrual cycle—they build up tissue each month, then break down and bleed during menstruation. But unlike the uterus lining, when these endometrial implants(also called growths or lesions) outside the uterus bleed, they can irritate a woman's body.

What causes endometriosis?

Despite continued medical research and investigation, the exact cause of endometriosis is unclear. But, there are several theories, including:

The Retrograde Menstruation Theory

This is the most widely accepted theory for the cause of endometriosis. During "retrograde menstruation," a woman's menstrual flow backs up through her fallopian tubes, implants in her abdomen, and grows. Some experts believe that all women experience retrograde menstruation, but that women with endometriosis may have either a hormonal or an immune system problem, and as a result, the implants are allowed to grow.

The Genetic Predisposition Theory

This theory suggests that endometriosis may be inherited—a woman who has female relatives with endometriosis may be more likely to develop the condition herself.

Other Theories

Another theory suggests that endometrial tissue is distributed from a woman's uterus to other parts of her body by the blood or the lymphatic system.

Yet another theory suggests that endometriosis is caused by coelemic metaplasia, or cells transforming into endometrial cells, perhaps after stimulation by menstrual blood.

What problems are caused by endometriosis?

71 to 87% of women studied with chronic pelvic pain were found to have endometriosis. Scar tissue buildup is thought to be a cause of chronic pelvic pain.

A woman may experience other symptoms including painful menstruation and pain during sexual intercourse.

Among infertile women, about 30 to 45% have endometriosis.

Symptoms

Not all women with endometriosis will have the same experience. In order to have a beneficial discussion with your doctor, it is important for you to become familiar with some of the most common signs and symptoms of the disease. They are:

• Irregular vaginal bleeding
• Chronic Pelvic Pain
• Dysmenorrhea, pain during and or after sexual intercourse
• Dysmenorrhea, pain before and during menstruation
• Infertility
• Painful bowel movements during menstruation

It is also important to know that the amount of pain you may be experiencing is not related to the number or size of your endometrial growths. Some women with visible disease at laparoscopy have no pain, while others without visible disease experience severe pain. This may be one reason why an accurate diagnosis of the disease can be very challenging.

One way you can partner with your doctor in his or her diagnosis is through a detailed talk about your symptoms, and the effect they are having on you.

You can also prepare to talk with your doctor by keeping track of your monthly pain and sharing the printouts at your next visit. Working together with your doctor can help you get answers to the questions you have about your symptoms.

You may be experiencing chronic pelvic pain and other endometriosis-related symptoms, but only a doctor can determine whether or not you have the disease. Your doctor may arrive at a diagnosis of endometriosis using a surgical or non-surgical method.

Surgical method

Endometriosis can be diagnosed through a procedure called laparoscopy. During this outpatient surgical procedure, a slender light-transmitting tube is inserted into a woman’s abdomen through her navel. This procedure lets the doctor examine the condition of a woman’s abdominal organs and check for the presence, size, and location of endometrial growths. If a doctor sees any growths, he or she may treat them surgically. However, growths may be hidden. A woman can have few visible lesions and experience severe pain, or have many visible lesions and feel little or no pain.

Non-surgical method

Many doctors rely on a history of a woman’s symptoms and a clinical workup using a 3-month trial of a GnRH agonist (GnRHa).to treat suspected endometriosis. Often, these two factors are all the doctor needs to make a diagnosis and then continue with GnRHa therapy—without laparoscopic surgery.

One way you can partner with your doctor in his or her diagnosis is through a detailed talk about your symptoms.

If you are diagnosed with endometriosis, your doctor will consider your age, symptoms, and desire for pregnancy before prescribing a course of therapy individualized to your needs.

Your doctor may recommend treating your endometriosis with surgical therapy (surgically removing or destroying endometrial growths), or medical therapy (reducing growth size and providing symptom relief). In many cases, your doctor may suggest a combination of surgical and medical therapy.

Read on to find out more about your treatment options.

Together, you and your doctor can decide whether medical therapy, surgical treatment, or a combination of surgical and medical treatment is appropriate for you. These three treatment options are outlined here to help you have a well-informed discussion with your doctor.

Surgical treatment

To surgically remove endometrial growths, a doctor will usually perform a procedure called laparoscopy. During laparoscopy, a slender, light-transmitting tube is inserted into a woman’s abdomen through her navel. The laparoscope allows doctors to see the size and extent of endometrial growths, and to remove as many of them as possible.

Since endometrial growths commonly occur in places where they are difficult for a surgeon to see and remove or dangerous to remove, such as under a woman’s uterus and in her bowel area, a doctor may prescribe medical therapy in addition to surgery. Read more about this option in combination therapy, below.

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Medical therapy

Another way a doctor may choose to treat endometriosis is with a gonadotropin-releasing hormone agonist (GnRHa). GnRHa can be used either with or without surgery, and can be effective regardless of whether a woman has few visible lesions or many.

Medical therapy with a GnRHa such as Lupron Depot^® temporarily lowers the levels of estrogen in a woman’s body. Lupron Depot reduces endometriotic growths, and provides pain relief.

Read more about how Lupron Depot works to treat endometriosis.

Lowering hormonal levels can also cause side effects, such as temporary bone density loss and hot flashes. Bone density loss may be partially or completely recovered after you stop therapy, and hot flashes will generally disappear. To manage these side effects, your doctor may prescribe add-back therapy, (norethindrone acetate 5 mg daily), in addition to Lupron Depot.

While treatment with Lupron Depot^® can manage your endometriosis symptoms, lowered hormone levels can cause you to experience temporary side effects such as bone density loss and hot flashes. There is good news. With add-back therapy, you can help to minimize these common side effects of Lupron Depot.

What is add-back therapy?

If your doctor prescribes Lupron Depot to manage your endometriosis, add-back therapy may also be included as part of your treatment program. Add-back therapy is a pill (norethindrone acetate 5 mg daily) that adds back low levels of a hormone without interfering with the effectiveness of Lupron Depot. It significantly reduces the bone density loss associated with the use of Lupron Depot. It can also help reduce hot flashes.

Add-back therapy can be given with an initial six-month course of Lupron Depot therapy. If an additional course of Lupron Depot is necessary, add-back therapy should be included in the treatment regimen. Lupron Depot lowers the levels of female hormones in your body and interrupts your monthly cycle. When you have endometriosis, reducing the hormone levels can be beneficial. However, lower hormone levels may cause side effects, including bone density loss and hot flashes.

Benefits of add-back therapy

Clinical studies have shown that taking norethindrone acetate 5 mg daily as add-back therapy while using Lupron Depot can help manage these side effects. Add-back therapy works by counteracting some of the effects of decreased hormone levels in your body. The benefits of add-back therapy may include:

• A significant decrease in bone density loss
• A reduction in the frequency of hot flashes you have each day, as well as a decline in the number of days you have hot flashes
• No decrease in the effectiveness of Lupron Depot in relieving the pain associated with endometriosis

When to consider add-back therapy

When discussing Lupron as a treatment option, make sure to talk with your doctor about whether add-back therapy is appropriate for you.

If bone density loss is a particular concern, or if your family has a history of osteoporosis, talk with your doctor about add-back therapy. If you are concerned about hot flashes, tell your doctor.

If your pain returns after completing Lupron Depot therapy alone, your doctor may prescribe Lupron Depot plus add-back therapy for an additional 6 months.

Combination therapy

Doctors often prescribe medical therapy such as Lupron Depot following laparoscopy. This is because even the most skilled surgeon may not be able to remove all endometrial growths due to their size, depth, and location. Over time, the implants may recur, causing a return of the same symptoms that led to the original surgery. Lupron Depot can treat growths remaining after surgery, and potentially extend a woman's symptom-free phase.

Doctors can also begin treatment with a GnRHa such as Lupron Depot based on symptomology. During this time, a doctor starts a woman on a 3-month trial of Lupron Depot to treat suspected endometriosis. If it is working to manage the disease, the doctor may continue with an entire 6-month regimen.

You can help your doctor evaluate your therapy options by keeping track of your monthly symptoms in a Pain Diary, and sharing the information at your next appointment.

Understanding how Lupron Depot^® works and what to expect during the different stages of therapy can be an important part of treating endometriosis. The more you know, the better equipped you will be to share your experiences and concerns with your doctor, and this can help him or her to optimize your treatment.

How Lupron Depot works

Lupron Depot, like other gonadotropin-releasing hormone agonists (GnRHa), works to manage endometriosis by lowering hormone levels. It is this lowering of hormone levels that decreases endometrial growths and provides symptom relief.

Dosage options

Lupron Depot is available as an injection (shot) that can be given by a doctor or healthcare provider once every 3 months (11.25 mg) or once each month (3.75 mg) for a 6-month treatment period. The dosage form you and your doctor select will determine how often you need to visit your doctor’s office for an injection.

Add-back therapy

Since treatment with Lupron Depot lowers hormone levels, during treatment with Lupron Depot you may experience side effects such as bone density loss and hot flashes. Bone density loss may be partially or completely recovered after you stop therapy, and hot flashes will generally disappear. From day one of therapy, your doctor can help decrease these side effects by prescribing Lupron Depot with add-back therapy.

Add-back therapy is a pill (norethindrone acetate 5 mg daily) that adds back low levels of a hormone without interfering with the effectiveness of Lupron Depot. It reduces the bone density loss associated with the use of Lupron Depot. It can also reduce hot flashes.

Read on to learn more about what you can expect during and after Lupron Depot therapy.

For more information on endometriosis and Lupron visit http://www.endofacts.com/