Medical treatment

1. Initial therapy also should include a nonsteroidal anti-inflammatory drug.

a. Naproxen (Naprosyn) 500 mg followed by 250 mg PO tid-qid prn [250, 375,500 mg].

b. Naproxen sodium (Aleve) 200 mg PO tid prn.

c. Naproxen sodium (Anaprox) 550 mg, followed by 275 mg PO tid-qid prn.

d. Ibuprofen (Motrin) 800 mg, then 400 mg PO q4-6h prn.

e. Mefenamic acid (Ponstel) 500 mg PO followed by 250 mg q6h prn.

2. Progestational agents. Progestins are similar to combination OCPs in their effects on FSH, LH and endometrial tissue. They may be associated with more bothersome adverse effects than OCPs. Progestins are effective in reducing the symptoms of endometriosis. Oral progestin regimens may include once-daily administration of medroxyprogesterone at the lowest effective dosage (5 to 20 mg). Depot medroxyprogesterone may be given intramuscularly every two weeks for two months at 100 mg per dose and then once a month for four months at 200 mg per dose.

3. Oral contraceptive pills (OCPs) suppress LH and FSH and prevent ovulation. Combination OCPs alleviate symptoms in about three quarters of patients. Oral contraceptives can be taken continuously (with no placebos) or cyclically, with a week of placebo pills between cycles. The OCPs can be discontinued after six months or continued indefinitely.

4. Danazol (Danocrine) has been highly effective in relieving the symptoms of endometriosis, but adverse effects may preclude its use. Adverse effects include headache, flushing, sweating and atrophic vaginitis. Androgenic side effects include acne, edema, hirsutism, deepening of the voice and weight gain. The initial dosage should be 800 mg per day, given in two divided oral doses. The overall response rate is 84 to 92 percent.

Medical Treatment of Endometriosis

Drug

Dosage

Adverse effects

Danazol (Danocrine)

800 mg per day in 2 divided doses

Estrogen deficiency, androgenic side effects

Oral contraceptives

1 pill per day (continuous or cyclic)

Headache, nausea, hypertension

Medroxyprog esterone

(Provera)

5 to 20 mg orally per day

Same as with other oral progestins

Medroxyprog esterone suspension

Provera)

100 mg IM every 2 weeks for 2 months; then 200 mg IM every month for 4 months or 150 mg IM every 3 months

Weight gain, depression, irregular menses or amenorrhea

Norethindron e (Aygestin)

5 mg per day orally for 2 weeks; then increase by 2.5 mg per day every 2 weeks up to 15 mg per day

Same as with other oral progestins

Leuprolide (Lupron)

3.75 mg IM every month for 6 months

Decrease in bone density, estrogen deficiency

Goserelin (Zoladex)

3.6 mg SC (in upper abdominal wall) every 28 days

Estrogen deficiency

Nafarelin (Synarel)

400 mg per day: 1 spray in 1 nostril in a.m.; 1 spray in other nostril in p.m.; start treatment on day 2 to 4 of menstrual cycle

Estrogen deficiency, bone density changes, nasal irritation

C. GnRH agonists. These agents (eg, leuprolide [Lupron], goserelin [Zoladex]) inhibit the secretion of gonadotropin. GnRH agonists are contraindicated in pregnancy and have hypoestrogenic side effects. They produce a mild degree of bone loss. Because of concerns about osteopenia, "add-back" therapy with low-dose estrogen has been recommended. The dosage of leuprolide is a single monthly 3.75-mg depot injection given intramuscularly. Goserelin, in a dosage of 3.6 mg, is administered subcutane-ously every 28 days. A nasal spray (nafarelin [Synarel]) may be used twice daily. The response rate is similar to that with danazol; about 90 percent of patients experience pain relief.

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