Are gonadotropin-releasing hormone analogs and laparoscopic ablation equally
effective treatments for endometriosis?
Rachel Baker, PA-S and Patricia Bunton, MS, PA-C
Department of Physician Assistant
Wichita State University, Wichita, KS
INTRODUCTION
Endometriosis is a disease of the female
reproductive system in which endometrial tissue
exists outside of the uterus and is found attached
to other organs, predominantly in the peritoneal
space. Approximately 10 to 25 percent of women
in the United States of reproductive age endure
this disease, and the prevalence is 3 to 4 times
greater in infertile women than in fertile women.
Endometrial tissue implants respond to normal
hormonal stimulation, thus cycle through
thickening, shedding and bleeding phases
simultaneously with the menstrual cycle.
Common symptoms include dysmenorrhea,
dyspareunia, rectal bleeding, infertility, severe
abdominal cramping and low back pain prior to or
during menses. Laparoscopic ablation (LA) is a
surgical treatment that has been available for
years and is the preferred treatment for infertile
patients or patients with progressed disease.
Another treatment option is the use of
gonadotropin-releasing
hormone
analogs
(GnRHa). Nafarelin, leuprolide acetate and
goserelin are examples of GnRHa drugs.
METHODS
This evidenced-based literature review
compares the use of GnRHa therapy and
laparoscopic ablation with respect to
symptom relief, recurrence of symptoms,
safety, side effects of treatment and
improvement of quality of life in women ages
18-50 with diagnosed endometriosis.
RESULTS
GnRHa - 12 clinic trials support effectiveness at minimizing
symptoms from 6 months to 1 year
Pregnancy rates - 50% increased after treatment with
leuprolide acetate [1]
Side Effects of GnRHa: non-life threatening, hypoestrogenic
and include mood changes, hot flashes, decreased bone
mineral density, vaginal bleeding, spotting or dryness, mild
depression and headache
Recurrence of symptoms with GnRHa: high at
approximately 50% [2]
LA – 7 of 9 clinical trials show effectiveness at reducing
symptoms up to 1 year
No significant increase in pregnancy rates after LA
Complications of Surgery: Low-incidence of adhesions,
bowel/ureteral injury and infection
Recurrence of symptoms after LA: one study indicated 12 of
14 patients had significant reduction or disappearance of
symptoms - repeat laparoscopy showed no re-implantation
of endometrial tissue. [3]
Three studies excluded - addressed chocolate cysts instead
of endometrial implants or the surgical procedure performed
was unclear.
Figure 1 - Literature Review Diagram
DISCUSSION
Literature concerning treatment for endometriosis
is difficult to compare because no two research
studies compare the same outcomes, use
comparable methods and research relies on the
subjective evaluation of the patients’ symptoms.
Many women have evidence of severe
endometriosis without symptoms while others have
minimal disease with severe symptoms. Therefore,
definitive treatment recommendations can not be
made based on subjective evidence.
CONCLUSIONS
Therapy for endometriosis is dependent on multiple
factors including the patient’s level of pain and
discomfort, improvement of symptoms with
treatment, incidence of symptom recurrence, ability
and
desire
to
conceive
and
side
effects/complications of treatment. To determine
and recommend the most effective and beneficial
treatment for each individual patient, all of these
factors should be evaluated and considered. This
evidence-based review recommends that both
GnRHa and LA are safe, reduce symptoms and
improve the overall quality of life; however, more
clinical research is needed in order to determine
specific
parameters
for
each
treatment.
Recommendations for safety and side effects of
each treatment were based on Level 1 and 2
evidence-based research.
REFERENCES
1. Tummon IS, Pepping ME, Binor Z, Radwanska E, Dmowski WP. A randomized, prospective
comparison of endocrine changes induced with Intranasal leuprolide or danazol for treatment
of endometriosis. Fertility and Sterility. 1989;51(390):390-394.
2. Wellbery C. Diagnosis and treatment of endometriosis. American Family Physician. October
15 1999;60(6):1753-1762.
3. Winkel CA, Scialli AR. Review: Medical and Surgical Therapies for Pain Associated with
Endometriosis. Journal of Women's Health & Gender-Based Medicine. 2001;10(2):137-162.