Reviews in Endocrine and Metabolic Disorders: Published: August 2021

Endometriosis is a chronic disease characterized by the presence of endometrium-like tissue outside the uterine cavity, affecting women of reproductive age with pelvic pain and infertility deeply affecting women’s health.

The most common symptoms of endometriosis are menstruation-related pain, i.e. dysmenorrhea, dyspareunia, dysuria and dyschezia, and noncyclic pelvic pain may also occur in these patients.

The prevalence ranges between 2 and 10% of women in reproductive age, 30–50% among infertile women, and 5 to 21% among women with severe pelvic pain.

This review aims to provide a comprehensive state-of-the-art on the current and future hormonal treatments for endometriosis, exploring the endocrine background of the disease.

TAKE HOME MESSAGE

Endometriosis requires a long term management. Currently, hormonal treatments are the most effective drugs for the treatment of endometriosis and are based on the pathogenic mechanisms involved in the disease.

The goal is to stop cyclic menstruation: by blocking ovarian estrogen secretion or by causing a pseudopregnancy state.

First-line hormonal therapies include progestins, while second-line therapy are represented by GnRH agonists (GnRH-a) and antagonists. The off-label use of combined oral contraceptives (COCs) is common. 

GnRH-a (goserelin, leuprolide, nafarelin, buserelin, and triptorelin) agonists and GnRH antagonists (elagolix) are effective on endometriosis by acting on pituitary-ovarian function.

However, treatment with GnRH-a is associated with significant hypoestrogenic side effects, including amenorrhea, vasomotor symptoms, sleep disturbance, urogenital atrophy, and accelerated bone loss. Therefore, GnRH-a should be used carefully in adolescents since these women may not have reached maximum bone density.

Progestins (dienogest (DNG) norethindrone acetate (NETA) and medroxyprogesterone acetate (MPA) are mostly used for long term treatments and act on multiple sites of action.

Nowadays, all these hormonal drugs are considered the first-line treatment for women with endometriosis to improve their symptoms, to postpone surgery or to prevent post-surgical disease recurrence.

Conclusions

Endometriosis is a chronic disease requiring a lifelong management. Based on patient’s symptoms and the desire of pregnancy, an individualized approach aiming to reduce pain, stress, stress-related comorbidities and to improve QoL should be used for an adequate management.

Medical hormonal treatment should be the first-line therapeutic option also for patients who have not an immediate desire to become pregnant.