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Popular and Lesser-Known Treatments for Endometriosis and Adenomyosis

Endometriosis and adenomyosis are very common gynecological disorders of our time. We asked Christian Becker - Associate Professor and Co-Director of the Oxford Endometriosis CaRe Centre - what the treatment options for the both are. And this is what we found out.

Previously, professor told us about the differences between endometriosis and adenomyosis. 

Now let’s talk about treatment options. What are they?

So, adenomyosis - pill, pill, pill, and the Mirena coil or vice versa.

The Mirena coil may be an earlier approach, but having a coil is a small procedure. There is a smaller version of the Mirena coil now available. It's a slightly smaller device and therefore easier to introduce into the womb but still invasive. So, that's probably the main approach with adenomyosis. However, once it is in and works, the woman does not have to worry about forgetting to take medication and has high reliability of contraception.

There is the entire spectrum of endometriosis drugs you can use for adenomyosis, that’s fine, but we usually suggest as prescribed treatment the Mirena coil. 

And for endometriosis, it’s exactly the same - pill, pill, pill and the Mirena coil. I'm not aware of any studies, that doesn't mean they don't exist, where they looked at implants for adenomyosis. Theoretically, it should work as well.

There are some older studies for Depo-Provera (Depo-Medroxy Progesterone Acetate). A lot of patients are not necessarily happy with them. It's nice if it works for you and your period stops. But there is a higher risk of gaining weight with that type of drug, and if you are trying to become pregnant in the foreseeable future afterward, there is often a three to six months lag between stopping the drug and until your periods return. 

So, for someone who says “I don’t want to have children in the foreseeable future” that’s fine. 

With that drug, you also have to be a bit careful for younger girls or women because of the bone mineral density, and the same is true for the GnRH agonists as we have them at the moment. 

Depo-Provera is nice if it works for you and your period stops. But there is a higher risk of gaining weight with that type of drug, and if you are trying to become pregnant in the foreseeable future afterward, there is often a three to six months lag between stopping the drug and until your periods return.

We should not give GnRH agonists by itself for more than six months. At the moment, the national and international guidelines say to give it together with HRT to protect the bones and alleviate the menopausal symptoms, which is fine. 

Practically, what we often do is we treat them for two or three months without HRT, obviously telling them what's going to happen to their general well-being, but if it helps with the pain then we know we can add HRT afterward which will protect the bones and then go from there. If the pain doesn't improve within two or three months then there's no point in continuing. Whereas if you start with HRT in the beginning, and it doesn't work, you're always worried, is it because you give too much estrogen, and that's why we usually start without it. 

GnRH antagonists: what are they?

Recently, in the US and Canada, they received FDA approval for a new class of drugs, called GnRH antagonist (gonadotropin-releasing hormone antagonists) and there are another two or three similar drugs coming up as well through trials.

Antagonists have the benefit of not needing a monthly injection or a three-month injection so it can be given orally which to some people is preferred. 

The issued therapy probably has very similar side effects regarding bones and menopausal symptoms as the agonists. So antagonists and agonists are pretty similar but benefit potentially in the future maybe that if you have a tablet you could probably reduce the dosage there. It’s important that maybe you can titrate a little bit how much of the tablet you take and, therefore, instead of adding HRT, maybe you're able to reduce the estrogen levels not as severely if you give a smaller dose of the GnRH antagonist. And if we're going to give HRT we still don't activate endometriosis. So I think that's what's out at the moment.

Aromatase inhibitors

There are also aromatase inhibitors which some centers use as a third-line approach due to their negative side effect profile. The use of these drugs is based on the observation that endometriosis tissue itself produces the enzyme aromatase which is necessary for the final step of estrogen production.

I think there's a strong will at least, to get away from hormonal approaches just because hormones are not necessarily great especially if you're trying to become pregnant.

What's next?

And looking at what the companies have in the pipeline, I think there's a strong will at least, to get away from hormonal approaches just because hormones are not necessarily great especially if you're trying to become pregnant.

Remember, many women who are suffering from both conditions are young and possibly would like to have children. So, companies are starting to look into drugs that are more disease pathway-specific and not an only hormone but other things as well. Whether it will work or not we will find out. 

Also, the problem could be that if they had a very new drug it is unclear whether it would have a detrimental effect on offspring which is why clinical trials always use contraception in parallel.

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