Minimal to mild endometriosis: 4 treatment options

Laparoscopic treatment of endometriosis is sometimes combined with ovarian suppression to improve success or facilitate surgical procedures.

Preoperative medical therapy, for example, suppresses ovulation so that functional cysts are not present, since they may be confused with endometriosis. Metastatic or extensive superficial disease is suppressed and becomes atrophic. Other uses of GnRH agonists prior to surgery include reducing symptoms, increasing the time available for adequate preoperative evaluation, facilitating scheduling, and even delaying or avoiding surgery for a woman nearing menopause.

Potential disadvantages of preoperative medical treatment include the changed appearance of endometriosis, which may make the disease more difficult to diagnose; drug cost and side effects; delay of diagnosis; and delay in attempting pregnancy.

Postoperative medical treatment. GnRH agonists may be indicated postoperatively if complete resection of disease has not been accomplished or for treatment of pain. Preoperative or postoperative treatment usually is given for 2 to 6 months, but 3 months is adequate for most women. An especially successful treatment approach for patients who do not desire pregnancy is to give OCs continuously for 2 to 3 months after surgery, withdraw for 1 week, and repeat the 2 to 3 months of treatment. In a few cases, where indicated, OCs can be continued until menopause or until the patient wishes to attempt pregnancy. It is the most cost-effective approach for many patients.

Treatment outcomes

Pain. If a woman has persistent pain after several months of expectant management, such as the patient described at the opening of this article, continuous OCs (3 months on, 1 week off) and GnRH agonists appear to be similarly effective. Approximately 80% to 90% of patients experience significant relief while on OCs or GnRH agonists, but more than 50% have some dysmenorrhea by 6 months after the agent is discontinued.⁹

• Laparoscopic treatment also is effective in treating pelvic pain, with approximately 60% to 100% of patients showing significant clinical improvement following complete resection of disease.¹⁰ Of patients who have relief of pain at 6 months after conservative surgery, 90% continue to have decreased pain at 1 year.¹¹
  
• Hysterectomy with oophorectomy results in a very high probability of “cure,” but should be avoided, if possible, in young women with minimal or mild disease. There is a small recurrence rate after hysterectomy, in the range of 5% to 8%.¹² This rate may be reduced by meticulous resection of all endometriosis at the time of hysterectomy and by performing concomitant oophorectomy.
  
• Fertility treatment. Controlled ovarian hyperstimulation with clomiphene citrate (150 mg every day from cycle day 3 to 7) or gonadotropins and intrauterine insemination improves pregnancy rates in this group. Most patients will conceive within 3 to 6 cycles of clomiphene treatment; thus, therapy should not continue past that time.
  
• Medical treatment delays conception. Ovarian suppression for minimal and mild endometriosis merely delays the possibility of pregnancy by the duration of the therapy and is associated with additional cost and undesirable side effects. For that reason, medical therapy should not be used to treat minimal and mild endometriosis when the only symptom is infertility.
  
• Pregnancy after laparoscopy. A review of laparoscopic treatment of endometriosis reported pregnancy rates for minimal and mild disease of 58% whether treated by electrocoagulation or by CO₂laser.¹⁷
  

Choosing a management approach

Treat disease at time of diagnosis. Endometriosis cannot be fully diagnosed without laparoscopy. Whether the patient’s symptoms involve pain or infertility, surgical treatment involving complete laparoscopic resection of the disease should be performed at the time of diagnosis, provided the surgeon is sufficiently skilled.¹⁸ The only exceptions to this approach are:

• patients given a presumptive diagnosis of endometriosis who plan to undergo a trial of medical therapy for pain, and
  
• young women with infertility as the sole symptom and extensive superficial peritoneal and/or ovarian disease. Treatment of such lesions may increase pregnancy rates, but also can lead to pelvic adhesions.
  

If the patient has adequate surgical extirpation of the disease, no further postoperative medical treatment is indicated (except for OCs), for either pain or infertility. If pain recurs, GnRH agonists usually should be the first line of treatment.

For infertile patients who fail to conceive, a second-look laparoscopy at 6 to 18 months is occasionally indicated, although in vitro fertilization may be more cost-effective, especially if other infertility factors are present.¹⁹