MANAGING HER PAIN

Is suppressing the ovulatory cycle enough?

According to American Congress of Obstetricians and Gynecologists (ACOG) guidelines:

Persistent symptoms are one reason to move on from initial treatment options, after first-line failure.1


Stopping the menses to reduce dysmenorrhea may not be enough to comprehensively address endometriosis pain.

Once inadequate pain relief on combined oral contraceptives or progestin-only contraceptives is identified, reasess your management plan.2,3

ACOG Treatment Algorithm for Endometriosis Pain. ACOG Treatment Algorithm for Endometriosis Pain.
*based on recommendations from ASRM and ACOG

ASK specific questions at every office visit to identify unresolved pain5,6

  • How has your pain changed since your last visit?
  • Has your pain lessened, or have you just grown accustomed to it?

View therapies for treating this estrogen-dependent disease1,4,7-10:

  • Inhibit the COX pathway
  • Reduce prostaglandin production
  • Decrease inflammation and primary dysmenorrhea
  • Combined OCs include both a synthetic progestin and estrogen
  • Progestin component helps prevent a rise in estradiol, but synthetic estrogen may result in continued proliferation of endometriosis
  • Continuous combined OCs can prevent estrogen fluctuation
  • Results in decreased secretion of estradiol and increases androgens
  • Decreases estradiol production and improves symptoms
  • Inhibit the production of LH and FSH, necessary triggers for stimulating the ovaries to produce estrogen
  • Suppress estrogen
  • Induce a hypoestrogenic state and improve symptoms
  • Unlike healthy endometrium, endometriotic tissue expresses a high level of aromatase activity that may increase estrogen levels and promote the growth of endometriosis lesions
  • Because they increase FSH levels and promote follicular development, aromatase inhibitors must be used with additional agents, such as GnRH agonists or combined oral contraceptives, in premenopausal women
  • Several small studies have shown aromatase inhibitors to be effective for the treatment of endometriosis and pelvic pain
  • Histologic confirmation of disease
  • Can effectively relieve painful symptoms
  • Symptoms may recur after surgery
  • Disease may be difficult to visualize and/or be present outside of the surgical window

Help your patients
with an action plan designed
for them.
Help your patients  with an action plan designed for them.

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References:

  1. American College of Obstetricians and Gynecologists. Practice bulletin no. 114: management of endometriosis. Obstet Gynecol. 2010;116(1):223-236.
  2. Vercellini P, Trespidi L, Colombo A, Vendola N, Marchini M, Crosignani PG. A gonadotropin-releasing hormone agonist versus a low-dose oral contraceptive for pelvic pain associated with endometriosis. Fertil Steril. 1993;60(1):75-79.
  3. Harada T, Momoeda M, Taketani Y, Hoshiai H, Terakawa N. Low-dose oral contraceptive pill for dysmenorrhea associated with endometriosis: a placebo-controlled, double-blind, randomized trial. Fertil Steril. 2008;90(5):1583-1588.
  4. Practice Committee of American Society for Reproductive Medicine. Treatment of pelvic pain associated with endometriosis: a committee opinion. Fertil Steril. 2014;101(4):927-935.
  5. Yeh J, Nagel EE. Patient satisfaction in obstetrics and gynecology: individualized patient-centered communication. Clin Med Insights Womens Health. 2010;3:23-32.
  6. Vercellini P. Introduction: management of endometriosis: moving toward a problem-oriented and patient-centered approach. Fertil Steril. 2015;104(4):761-763.
  7. Kodaman PH. Current strategies for endometriosis management. Obstet Gynecol Clin North Am. 2015;42(1):87-101.
  8. Danocrine [package insert]. Bridgewater, NJ: Sanofi-Aventis. US LLC; 2011.
  9. Lupron Depot [package insert]. North Chicago, IL: AbbVie Inc; 2016.
  10. Giudice LC. Clinical practice: endometriosis. N Engl J Med. 2010;362(25):2389-2398.