1. Endometriosis II ( Treatment ) Somkiat Sitavarin MD. Asso. Prof. Kamthorn Pruksananonda MD. ( Advisor )

2. Medical treatment of endometriosis Indication for treatment of endometriosis Pain : pelvic pain, dysmenorrhea, or dyspareunia Abnormal bleeding Pelvic pathology : ovarian cyst Infertility ? Prophylaxis

3. Modality of medical treatment for endometriosis Nonsteroidal anti-inflammatory drug Estrogen-progestogen combination : cyclic, continuous Progestogen : injectable, oral Danazol GnRH-a Antiprogestin Others

4. Therapeutic options Analgesic NSAIDS inhibit biosynthesis of PGs and alleviate symptoms Well tolerated, safe and inexpensive and are recommended as a first-line of treatment in mild symtoms

5. Therapeutic options Combination of estrogen and progestin ( pseudopregnancy ) anovulation, amenorrhea and progressive decidualization then necrobiosis and resorption of ectopic endometrium Use of OC. (.020-.035 mg EE ) continuously 6-9 mos. Lowest dose to produce amenorrhea Side effects - abdominal swelling, depression,breast pain and tenderness, increase appetite, weight gain, edema to breakthrough bleeding.

6. Combination of estrogen and progestin ( pseudopregnancy ) Superficial varicosity occasionally appear, and there is an increase risk of DVT. Symptomatic relieve 75-100 %; Pregnancy rate ranged from 10-58 % Today, this regimen is not commonly used and initial treatment

7. Progestogens Progestogens used for management of endometriosis Parenteral MPA ( Provera ) Oral MPA ( Provera ) Megase Gestrinone Lyestrenol CPA

8. MPA 100 mg DMPA every 2 wks. 4 doses followed by 200 mg monthly 4 mos. When breakthrough bleeding occurred, EE.02 mg daily 25 days each month was added Other regimen consists of 150 mg every 3 mos. For 1 year Adequate data to document the effectiveness of MPA to soppress endometriosis and enhance fertility are not available Spotting, depression, breakthrough bleeding, weight gain

9. Other Progestogen Gestinone ( R2323 ) Unsaturated 19-norsteroid Is a weak progestin and androgen agonist/ antagonist Suppress midcycle LH surgh and FSH and folliculogenesis Amenorrhea and symtomatic relieve in 85-90 % within 2 mos Side effects were moderate, transient and primarily related to androgenic and anabolic activities

10. Megestrol acetate Antiandrogenic effect and suppressive action on gonadotropin In retrospective study, using 40 mg/day for upto 24 weeks - 86% relieve symtoms Dydrogesterone ( Duphaston ) 20-30 mg/day 60 mg in luteal phase shown to relieve pain, neither regimen seem to improve pregnancy rates

11. CPA 17-OH progesterone derivatives In combination with EE. may be as effective as danazol to alleviate pain Antiandrogenic, antigonadotropic and progestational activities Side effects were fatigue, loss of libido, depression and weightgain

12. Antiprogestins ( RU 486 ) Bind to progesterone receptors and exert antiprogesterone and antiglucocorticoid activities Inhibit ovulation and disrupt endometrial integrity 100 mg/day for 3 mos. induce amenorrhea and decrease pelvic pain 50 mg/day for 6 mos. alsoso has been report Side effects were atypical flushes, anorexia and fatique

13. Danazol Isoxazole derivatives of 17-alpha-ethinyl testosterone Androgen and glucocorticoid agonist, suppression of Gn, inhibit ovarian steroidogenesis and alter immune response 400-800 mg/dy for 6 mos. with pregnancy be excluded Symtomatic relieve 60-100 %, dyspareunia relieve 80 % 0n second look assesment, almost 100 % resolute in minimal-mild, 50-70 % in advanced disease

14. Danazol Side effects were weight gain, acne, hirsutism, oily skin and decrease in breast size, muscle cramp, flushing, mood changes, depression and edema HDL decrease, LDL increase, VLDL not changed,