Hormonal treatment

Hormonal treatment of endometriosis

Endometriosis is an oestrogen-dependent condition - the hormone stimulates lesion growth and worsens symptoms. Hormonal treatment works by suppressing menstruation, reducing oestrogen levels in the body and thereby preventing further lesion growth and relieving pain.

Hormonal treatment does not remove lesions - it only slows their growth and suppresses symptoms. Symptoms may return after stopping. It also does not improve the chances of conceiving - it is therefore not a suitable choice for women being treated for infertility.

When is hormonal treatment appropriate?

• as first-line treatment for women with mild to moderate symptoms
• after surgery to delay potential disease recurrence
• for women who do not plan pregnancy in the near future
• as long-term maintenance treatment between operations

Combined hormonal contraception

Pills containing oestrogen and progestin are most commonly the first-line treatment. They suppress ovulation, reduce oestrogen levels and significantly relieve menstrual pain and bleeding. They can be taken continuously - without a break - completely avoiding menstruation.

Advantages include availability, low cost and suitability for long-term use. Side effects are usually mild - nausea, breast tenderness, mood changes. Unsuitable for women with risk of blood clotting.

Progestins

Preparations containing only progestin (without oestrogen) have been used in the treatment of endometriosis since the 1950s. They suppress endometrial implant growth and cause their gradual atrophy. Approximately 3 out of 4 women (75%) experience significant pain relief with progestins.

Most commonly used progestins and dosages:

• Dienogest (Visanne) - 2 mg daily in tablet form; preparation specifically indicated for endometriosis treatment with a favourable side effect profile
• Medroxyprogesterone acetate (Provera) - 30-60 mg daily or as a depot injection every 2-3 months
• Dydrogesterone (Duphaston) - 10-30 mg daily
• Norethisterone (Primolut N) - 2.5-5 mg daily
• Levonorgestrel intrauterine device (Mirena) - releases hormone locally for 5 years

Important: progestins are only effective with continuous daily use - taking them only in the second half of the cycle produces no effect.

GnRH analogues

GnRH analogues are powerful preparations that temporarily induce a menopause-like state - the ovaries stop producing oestrogen and endometriosis settles significantly. Available in four forms: monthly injection, quarterly injection, daily injection, nasal spray.

Most commonly used preparations: Zoladex (goserelin), Lupron Depot / Prostap (leuprorelin), Decapeptyl (triptorelin), Synarel (nafarelin).

Timeline of effects:

• first 2 weeks: some women experience a temporary worsening of symptoms - a normal response until oestrogen levels fall
• symptom improvement begins within 4-8 weeks
• bleeding stops in most women within 2 months
• menstruation returns 4-6 weeks after stopping the nasal spray, 6-10 weeks after injection

Standard treatment duration is 3-6 months. A three-month course relieves pain as effectively as six months, but six months delays symptom recurrence longer.

Add-back therapy

GnRH analogues cause menopause-like side effects - hot flushes, night sweats, vaginal dryness, headaches, mood changes, reduced libido. The most serious side effect is bone density loss - approximately 4-6% after a 6-month course, which mostly recovers within 18-24 months after treatment ends.

Add-back therapy - supplementation with a low dose of oestrogen, progestin or tibolone - significantly reduces these side effects without reducing GnRH efficacy. It enables repeated or continuous treatment courses for up to 2 years.

Important warning about GnRH

GnRH analogues should not be started before surgery for peritoneal (superficial) lesions - they reduce lesion visibility and complicate the surgeon's identification of them. They are also not suitable as a fertility treatment without assisted reproduction.

GnRH antagonists

A newer class of preparations - elagolix, relugolix - in tablet form with a similar effect to GnRH analogues but faster onset and the possibility of dose adjustment. Consult your doctor regarding availability in the Czech Republic.

Danazol

Danazol is an older preparation with androgenic effects, now used only occasionally due to pronounced side effects (weight gain, acne, increased body hair, voice changes).

How to choose the right preparation?

• Symptom intensity - severe pain or advanced endometriosis warrants stronger medications
• Side effect tolerance - each woman responds differently; it may be necessary to try and change preparations
• Duration of planned treatment - some preparations suit short-term, others long-term use
• Pregnancy planning - all hormonal treatment suppresses ovulation; treatment must be stopped in good time
• Health contraindications - blood clotting risk excludes combined contraception
• Bone density status - baseline values should be known before GnRH analogue treatment

What to do if treatment isn't working?

If hormonal treatment does not provide sufficient relief, tell your doctor. Options include changing the preparation or dosage, combining methods, adding physiotherapy or psychological support, or considering surgical treatment.

Accepting pain is not a solution. If your current treatment is insufficient, book a consultation with us.

Detailed information on hormonal preparations: endometriosis.org - Treatments.