Living with endometriosis: MedlinePlus Medical Encyclopedia

You have a condition called endometriosis. Symptoms of endometriosis include:

• Heavy painful menstrual bleeding
• Bleeding between periods
• Problems getting pregnant
• Chronic pelvic pain

Having this condition can interfere with your social and work life.

No one knows what causes endometriosis. There is also no cure. However, there are different ways to treat the symptoms. These treatments can also help relieve menstrual pain.

Learning how to manage your symptoms can make it easier to live with endometriosis.

Your health care provider may prescribe different types of hormone therapy. These may be birth control pills or injections. Be sure to follow your provider’s directions for taking these medicines. Do not stop taking them without talking with your provider. Be sure to tell your provider about any side effects.

Over-the-counter pain relievers can reduce the pain of endometriosis. These include:

• Ibuprofen (Advil)
• Naproxen (Aleve)
• Acetaminophen (Tylenol)

If the pain is worse during your periods, try starting these medicines 1 to 2 days before your period begins.

You may be receiving hormone therapy to prevent the endometriosis from becoming worse, such as:

• Birth control pills.
• Medicines that cause a menopause-like state. Side effects include hot flashes, vaginal dryness, and mood changes.

Apply a hot water bottle or heating pad to your lower stomach. This can get blood flowing and relax your muscles. Warm baths also may help relieve pain.

Lie down and rest. Place a pillow under your knees when lying on your back. If you prefer to lie on your side, pull your knees up toward your chest. These positions help take the pressure off your back.

Get regular exercise. Exercise helps improve blood flow. It also triggers your body’s natural painkillers, called endorphins.

Eat a balanced, healthy diet. Maintaining a healthy weight will help improve your overall health. Eating plenty of fiber can help keep you regular so you don’t have to strain during bowel movements.

Techniques that also offer ways to relax and may help relieve pain include:

• Muscle relaxation
• Deep breathing
• Visualization
• Biofeedback
• Yoga

Some women find that acupuncture helps ease painful periods. Some studies show it also helps with long-term (chronic) pain.

If self-care for pain does not help, talk with your provider about other treatment options.

If medicines do not control your symptoms, your provider may suggest a pelvic laparoscopy procedure.

Call your provider right away if you have severe pelvic pain.

Call your provider for an appointment if:

• You have pain during or after sex
• Your periods become more painful
• You have blood in your urine or pain when you urinate
• You have blood in your stool, painful bowel movements, or a change in your bowel movements
• You are unable to become pregnant after trying for 1 year

Pelvic pain – living with endometriosis; Endometrial implant – living with endometriosis; Endometrioma – living with endometriosis

Advincula AP, Truong M, Lobo RA. Endometriosis: etiology, pathology, diagnosis, management. In: Gershenson DM, Lentz GM, Valea FA, Lobo RA, eds. Comprehensive Gynecology. 8th ed. Philadelphia, PA: Elsevier; 2022:chap 19.

Brown J, Farquhar C. An overview of treatments for endometriosis. JAMA. 2015;313(3):296-297. PMID: 25603001 pubmed.ncbi.nlm.nih.gov/25603001/.

Burney RO, Giudice LC. Endometriosis. In: Jameson JL, De Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric. 7th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 130.

Hays BM, Hudson T. Endometriosis. In: Pizzorno JE, Murray MT, eds. Textbook of Natural Medicine. 5th ed. St Louis, MO: Elsevier; 2021:chap 166.

Kalaitzopoulos DR, Samartzis N, Kolovos GN, et al. Treatment of endometriosis: a review with comparison of 8 guidelines. BMC Womens Health. 2021;21(1):397. PMID: 34844587 pubmed.ncbi.nlm.nih.gov/34844587/.

Smith CA, Armour M, Zhu X, Li X, Lu ZY, Song J. Acupuncture for dysmenorrhoea. Cochrane Database Syst Rev. 2016;4:CD007854. PMID: 27087494 pubmed.ncbi.nlm.nih.gov/27087494/.

Updated by: John D. Jacobson, MD, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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Why I Recommend Ibuprofen to Women with Endometriosis

March is Endometriosis Awareness Month… and I feel like I’ve been spending most of this month talking to women who have more-than-usual pain when it comes to their periods. Many women can experience pain lingering from a dull ache, to so severe they cannot leave a fetal position for multiple days in a row. Endometriosis isn’t just a “pull yourself together dear” diagnosis, it can literally impact every part of a woman’s life. 

 But here’s the deal, research on endometriosis is severely lacking. We barely know why some women develop it, let alone how to treat it. In fact, many women don’t even get diagnosed with endometriosis until they’re having trouble trying to get pregnant. Lo and behold, when a proper history is taken, it turns out that the pain that woman has been suffering during her periods has never been taken seriously. The question then becomes, what do you do about it?

Gold Standard of Treatment

In Canada, the gold standard treatment for endometriosis is something known as excision surgery; and it’s not even available here in Atlantic Canada. If you want to experience relief, you usually have to fly to the States for surgery. Not cool. If you can’t afford it, you’re left with a few options.. painkillers, a birth control pill or IUD, Visanne (similar to a progesterone-only OCP) or a hysterectomy. Really not cool. 

This is where naturopathic medicine comes in. 

It’s interesting to me, how we’re not always following the research when it comes to increasing Quality of Life in women with Endometriosis. That’s why my first recommendation always throws women off. No matter what stage of Endometriosis, I always recommend Ibuprofen. 

No, not for the reason you think. Let’s face it; when you’re suffering from that much pain Ibuprofen isn’t going to cut it. You and I both know that. But Ibuprofen is known as a prostaglandin inhibitor. And inhibiting prostaglandins is critical when you have endometriosis. 

What is a Prostaglandin? 

Prostaglandins occur naturally, in response to injury or disease, and cause pain and inflammation.  They have a number of functions including making the womb contract during a period (which helps with the shedding of the lining). These contractions can cause pain and the (unfortunate) link to endometriosis is actually quite interesting. See, the endometrium (the tissue that lines the womb) is an important endocrine gland and secretes a family of hormones called prostaglandins (PGs). PGs are lipid (oil based) hormones that are directly responsible for most of the cramps and pain associated with menstruation and endometriosis.

In women with endometriosis, however, that endometrium isn’t just specific to the uterine area. The endometriosis deposits throughout the body also respond to hormones the same way that the uterine endometrium does. GREAT (please note the sarcasm). 

This means that you’re not just experiencing cramps and pain in one area; it can be EVERYWHERE.

The Pain Connection

There are 2 types of prostaglandin’s that we focus primarily on when it comes to the menstrual cycle. Prostaglandin F (PGF) stimulates strong uterine contractions or cramps, and Prostaglandin E (PGE) stimulates that excruciating pain. Large amounts of PGF and PGE are produced by the endometrium and also endometriosis deposits spread throughout your body. The endometrium and its straying implants are very responsive to the levels of these hormones circulating in your blood.

It’s incredibly important to note that there is a natural surge of PGF at the end of the menstrual cycle, causing the effects of the corpus luteum of the ovary to die down, signaling the start of the menstrual cycle. The longer it takes for you to start your period (aka if you spot for multiple days) or the larger the ratio between your estrogen and progesterone levels, the worse this pain gets. This surge is part of the reason that the start of your period is generally more painful that the end of your period. 

PGF also causes increased gut motility leading to Irritable Bowel Syndrome (IBS) and diarrhea, which is why many women (with or without a diagnosis of endometriosis) experience looser stools as their periods start. 

What’s Estrogen Have to Do With Endometriosis? 

You know that nice little ratio between estrogen and progesterone I mentioned above? Keeping that ratio as close together as possible is critical for keeping prostaglandins low. Endometriosis deposits throughout the body not only respond to estrogen like the endometrial lining of your uterus, they also produce estrogen on their own. 

This means that, in women with endometriosis, you see high high high levels of estrogen. High levels of estrogen equates to high levels of inflammation; which equates to heavier bleeding, more clots, and… you guessed it, higher levels of prostaglandins being released. 

So, why Ibuprofen?

As you’ve probably summarized, endometriosis is a complicated process in which no one pill, diet, or even surgery, can guarantee an outcome. That’s why we take a few different options and piece them together and then tweak and make changes off of genetics, symptoms and changes. 

My main focus when working with women with endometriosis is Quality of Life. Let’s say your pain is at a 9.5/10; we’re going to focus on dropping that to a 6/10, and then lessening it from there. You have 2.5 bad weeks a month (or more?), we’re going to aim to get that down to 1 week. And then keep working. 

But step one, is to drop the prostaglandins and try to lessen the bleeding (less bleeding = less inflammation = less pain = better periods). This is where Ibuprofen comes in, as taking ibuprofen not only reduces the prostaglandin release, it also reduces bleeding by 20-40%. But here’s the deal… ibuprofen only works effectively if they are taken BEFORE the body starts to produce prostaglandins. Which means you sometimes have to start taking them a few days before your period actually starts (if your stomach can handle it).

Once pain isn’t controlling your daily life, we then focus on adding in natural anti-inflammatories (like omega-3 fatty acids, SPMs, curcumin and boswellia), reducing foods that are high in linolenic acid (which increases prostaglandins), and bringing the ratio of estrogen and progesterone closer together by decreasing estrogen levels and increasing progesterone. 

If you’re interested in chatting more about how we can improve your Quality of Life, feel free to contact me using the form below. 

-Dr. Ashley

The use of ibuprofen in gynecological practice | Tikhomirov A.L., Lubnin D.M.

Pain syndrome accompanies a number of common
gynecological diseases and may be the main complaint that
the patient presents. Pain brings not only physical suffering, but also
always accompanied by severe emotional experiences.
Neurophysiologists argue that pain is to a large extent a derivative of higher nervous activity.
We are able to be aware of pain, to evaluate it, and at the same time pain
can influence the perception of the world as a whole, distort this perception and, in
eventually, with its long existence, to become the center of all
human life, passing everything through the prism of oneself. Pain is one of
the most intense human suffering. Pain can take over consciousness and
change personality. It is known that one of the outstanding German philosophers
of the last century, Nietzsche, who created a doctrine filled with quite
ambiguous judgments, suffered all his life from severe headaches
pain.

Probably, almost every woman at least once in her life faced such a condition as painful menstruation. For some, the pain syndrome during menstruation is so pronounced that it can lead a woman to a completely incapacitated state. In other words, pain in a woman’s life is not uncommon. At the same time, in gynecological practice, we often have to perform all kinds of invasive interventions, accompanied by pain, sometimes quite severe, in which it is usually not customary to use general anesthesia. In this situation, one has to resort to non-narcotic analgesics, the effectiveness of which can vary quite a lot. In this article, we want to touch on the issue of pain syndrome in gynecological practice and offer treatment options for this condition.

Dysmenorrhea or painful menstruation is one of the most common reasons women miss work or school. At many state-owned enterprises, there is still such a thing as “Women’s Day”, which allows a woman to go through “critical days” once a month not in the workplace.

Dysmenorrhea is divided into primary and secondary. Under primary dysmenorrhea understand painful menstruation in the absence of pathological changes in the genital organs. At secondary dysmenorrhea painful menstruation due to gynecological diseases. Most often these include endometriosis, inflammatory diseases of the genital organs, uterine fibroids and others. According to various authors, the incidence of dysmenorrhea, depending on age, ranges from 60 to 92%. Obviously, primary dysmenorrhea occurs predominantly in adolescents, while secondary is characteristic of older age groups.

Primary dysmenorrhea usually develops 6 to 12 months after menarche, when the first ovulatory cycles appear. Symptoms of dysmenorrhea usually occur with the onset of menses, rarely the day before, and are characterized by cramping, aching, twitching, arching pains that can radiate to the rectum, appendages, and bladder. In addition, nausea, vomiting, headache, irritability, bloating and other vegetative phenomena can be observed.

Among adolescents, the peak incidence of dysmenorrhea occurs at 17–18 years of age, that is, by the time the final formation of the menstrual function and the formation of the ovulatory menstrual cycle. This pattern, in particular, indicates the significant role of ovulation in the pathogenesis of primary dysmenorrhea.

Although there are still no unambiguous ideas about the etiology of primary dysmenorrhea, nevertheless, most researchers agree that the leading role in the development of this disease is played by prostaglandin imbalance in the uterus .

Back in 1978, it was shown that prostaglandin F _2a (PGF _2a ) and prostaglandin E ₂ (PGE ₂ ) accumulate in the endometrium during menstruation and cause symptoms of dysmenorrhea [1]. Prostaglandin F _2a and PGE ₂ are synthesized from arachidonic acid via the so-called cyclooxygenase pathway. The activity of this enzyme pathway in the endometrium is regulated by sex hormones, more precisely, by successive stimulation of the endometrium first by estrogens and then by progesterone. By the time of menstruation, a large concentration of prostaglandins accumulates in the endometrium, which, due to lysis of endometrial cells, are released outside. Prostaglandins released from the cells act on the myometrium, which leads to alternating constrictions and relaxations of smooth muscle cells. Uterine contractions caused by prostaglandins can last several minutes, and the developed pressure in the uterus can reach 60 mm Hg. Prolonged uterine contractions lead to the development of ischemia and, as a result, to the accumulation of anaerobic metabolic products, which, in turn, stimulate the C-type of pain neurons. In other words, primary dysmenorrhea can be called “uterine angina”.

The role of prostaglandins in the development of primary dysmenorrhea is confirmed by a study in which it was found that the concentration of prostaglandins in the endometrium correlates with the severity of symptoms, that is, the higher the concentration of PGF _2a and PGE ₂ in the endometrium, the more severe dysmenorrhea is [2].

Many factors can modulate the effect of prostaglandins on the uterus. For example, increased physical exercise can increase uterine tone, possibly by reducing uterine blood flow. Many athletes note that increased training during menstruation significantly increases the symptoms of dysmenorrhea. In addition to affecting the uterus, PGF _2a and PGE ₂ can cause bronchoconstriction, diarrhea and hypertension, in particular, diarrhea especially often accompanies primary dysmenorrhea.

For high production of prostaglandins in the endometrium, it is necessary sequential exposure to it at the beginning of estrogens, and then progesterone . Obviously, women with an anovulatory menstrual cycle extremely rarely suffer from primary dysmenorrhea due to their lack of sufficient secretion of progesterone. In this regard, the presence of ovulation is one of the factors that cause symptoms of dysmenorrhea.

The most common drugs for treating primary dysmenorrhea are oral contraceptives and non-steroidal anti-inflammatory drugs (NSAIDs). The purpose of oral contraceptives is mainly aimed at turning off ovulation, since, as noted above, it is the ovulatory menstrual cycle that provides cyclic stimulation of the endometrium, which contributes to the accumulation of prostaglandins responsible for the development of symptoms of dysmenorrhea. This method of treatment is quite effective, however, when choosing it, a number of factors must be taken into account. Firstly, most patients with primary dysmenorrhea are adolescents who do not live sexually, for whom the problem of concomitant contraception is not so relevant, and the belief in the inevitable weight gain “from hormones” is extremely strong. Secondly, it is not possible in all cases to prescribe oral contraceptives, since they have a number of contraindications. Thirdly, the therapeutic effect of the prescription of oral contraceptives develops only after 2-3 months from the start of their intake, which makes their prescription irrational in cases of a particularly severe course of the disease. Thus, the use of oral contraceptives for the treatment of primary dysmenorrhea is optimal in cases where the patient, in addition to treatment, requires reliable contraception, as well as in cases of mild to moderate symptoms.

Another equally effective approach to the treatment of primary dysmenorrhea is the appointment of NSAIDs, in particular, the drug ibuprofen (Nurofen) , the most widely used in world clinical practice.

Nurofen (ibuprofen) is a derivative of phenylpropionic acid. Nurofen inhibits the synthesis of prostaglandins by inhibiting the activity of cyclooxygenase. After oral administration, ibuprofen is rapidly absorbed from the gastrointestinal tract, its maximum plasma concentration is determined after 1-2 hours. Ibuprofen is metabolized in the liver, excreted by the kidneys unchanged and in the form of conjugates, the half-life is 2 hours. Unlike other NSAIDs, when using Nurofen, side effects are extremely rare, which are mainly characterized by mild digestive disorders. For the treatment of primary dysmenorrhea, Nurofen is prescribed at an initial dose of 400 mg, then the drug is prescribed at a dose of 200-400 mg every 4 hours, the maximum daily dose of Nurofen is 1200 mg. Obviously, the dose of Nurofen should be selected depending on the severity of the symptoms of the disease.

In the event that the analgesic effect of Nurofen is not enough, it is possible to use the combination drug Nurofen Plus . In this preparation, ibuprofen is combined with codeine, an analgesic that acts on opiate receptors in the central nervous system. This combination gives a more pronounced analgesic effect.

In general, the use of NSAIDs for the treatment of primary dysmenorrhea has a number of advantages over the use of oral contraceptives. Unlike oral contraceptives, which should be taken for several months, NSAIDs are prescribed only for 2-3 days a month, which, on the one hand, is more convenient, and on the other hand, more cost-effective. In addition, NSAIDs not only effectively neutralize the negative effects of prostaglandins on the uterus, but also eliminate other symptoms of dysmenorrhea, such as nausea, vomiting, and diarrhea.

Objectively speaking, it was the high efficacy of NSAIDs in the treatment of not only the main, but also the accompanying symptoms of primary dysmenorrhea that confirmed the hypothesis of the role of prostaglandins in the pathogenesis of this disease, and therefore it is obvious that NSAIDs are first-line drugs in the treatment of primary dysmenorrhea .

Although primary dysmenorrhea is one of the most common gynecological diseases accompanied by pain, a number of other gynecological pathologies often require the use of effective analgesics.

Secondary dysmenorrhea , as noted above, is due to the presence of organic disorders of the genitals (Table 1).

There are a number of factors that make it possible to distinguish secondary from primary dysmenorrhea.

1. Symptoms of dysmenorrhea appear during the first or second menstrual cycle after menarche (congenital obstructive malformations).

2. Symptoms of dysmenorrhea first appear over the age of 25 years.

3. The presence of gynecological diseases: infertility (suggested endometriosis, inflammatory diseases of the pelvic organs or other causes of adhesions), heavy menstruation or intermenstrual bleeding (suggested adenomyosis, uterine fibroids, polyps), dyspareunia.

4. Lack of effect or its insignificant severity from NSAID therapy and / or oral contraceptives.

The most common cause of secondary dysmenorrhea is endometriosis . The characteristic symptoms of endometriosis are: the appearance of progressively increasing pain that occurs immediately before or during menstruation; dyspareunia, painful bowel movements, premenstrual spotting and polymenorrhea; pain over the womb, dysuria and hematuria; infertility. A number of patients may not designate the pain syndrome as an acquired phenomenon, but simply note that they have painful menstruation, although most indicate increased pain in menstruation. The pain is most often bilateral and varies in intensity from slight to extremely pronounced, often the pain is associated with a feeling of pressure in the rectum and can radiate to the back and leg. Constant “discomfort” throughout the entire menstrual cycle, aggravated before menstruation or during intercourse, may be the only complaint made by a patient with endometriosis. The cause of the pain is not fully established, it is assumed that it may be associated with the phenomenon of “miniature menstruation” of endometrioid explants, which leads to irritation of the nerve endings. The disappearance of pain during the induction of amenorrhea in patients with endometriosis, that is, the exclusion of cyclic hormonal effects on endometrioid explants, in fact, proves the mechanism of the pain syndrome.

However, pain is not always associated with endometriosis, even in cases where the disease is severe. For example, bilateral large ovarian endometrioid cysts are most often asymptomatic unless they rupture, while severe discomfort may be due to a minimal number of active endometrioid heterotopias.

Despite the fact that there is a well-defined pathogenetic therapy for endometriosis, including the use of GnRH agonists and derivatives of 19-norsteroids, quite often at the first stages of treatment, and sometimes for longer periods, analgesics have to be added to the main drugs. This is due to the fact that the basic drugs do not have their maximum effect immediately, in some cases, the basic drugs are not able to completely eliminate the pain syndrome. Thus, the drug Nurofen or Nurofen Plus also finds its place in the treatment of endometriosis.

Daily gynecological practice can not do without such procedures as the introduction and removal of intrauterine devices, treatment of cervical pathology, endometrial biopsy, hysterosalpingography, etc. Of course, in most cases, you can not use painkillers at all for these interventions. The era of abortions performed without any anesthesia has not yet been forgotten. One could simply yell at the patient – “be patient, this was not tolerated during the war” – and that’s it, but in modern conditions this is completely unacceptable. Moreover, all the procedures listed above can be anesthetized quite well and thereby achieve good emotional tolerance of these interventions. For this purpose, it is also possible to use Nurofen Plus, preferably 20–30 minutes before the procedure and subsequently after its completion. One or two doses of this drug, depending on the severity of the pain syndrome, will provide pleasant memories on the part of the patient about a caring doctor.

We would like to touch on another, fairly common pain syndrome in the framework of this story. This is the so-called pelvic ganglioneuritis . This is a variant of sciatica, in which there is a pinching of the nerve trunks that extend into the pelvic area. Patients with this disease most often complain of recurrent pain in the iliac regions. As a rule, the examination fails to reveal any signs of an inflammatory process in the uterine appendages, or any other pathological changes. The pain syndrome in such patients is quite well stopped by taking analgesics from the NSAID group, in particular Nurofen.

Since 2001, in our clinic, for the treatment of patients with uterine myoma , we began to use the method of uterine artery embolization. After the procedure, patients usually experience pain of varying severity. The duration of this syndrome also varies, but the average is 8 days. We used various pain relief regimens in this category of patients and settled on a scheme that included the use of Nurofen and Nurofen Plus. In particular, we were able to note a more pronounced analgesic effect of this drug, a quick onset of the effect and good tolerance.

Thus, Nurofen and Nurofen Plus are widely used in gynecological practice, effectively relieving women from pain.

Literature:

1. Ylikorkala O, Dawood M.Y. New concept in dysmenorrhea. Am J Obstet Gynecol 1978; 130:833

2. Chan W.Y., Dawood M.Y., Fuchs F. Relief of dysmenorrhea with the prostaglandin synthetase inhibitor ibuprofen: effect of prostaglandin levels in menstrual fluid. Am J Obstet Gynecol 1979; 135:102.

Medical treatment of endometriosis

Since there is still no universal drug therapy for endometriosis, all treatment is non-specific, aimed mainly at reducing the severity of existing symptoms and is selected individually, based on the characteristics and needs of each patient.

Endometriosis is often characterized by a persistent relapsing course, therefore, when choosing a treatment, special attention should be paid not only to its effectiveness, but also to long-term safety and tolerability, due to the fact that quite long-term therapy may be necessary. The cost-effectiveness of the treatment must also be taken into account.

It should be remembered that laparoscopy is not always necessary before initiating medical therapy for pelvic pain in cases of suspected endometriosis and no anatomical changes (with the exception of endometrioid ovarian cysts).

In the treatment of endometriosis, any methods of drug therapy should be used for 3 months in the absence of contraindications and side effects, after which its effectiveness is evaluated and, if necessary, the drug is changed or laparoscopy is performed.

With the complete removal of histologically verified endometrioid ovarian cysts (enucleation of the capsule or vaporization), as well as foci of endometriosis on the peritoneum of the small pelvis, sacro-uterine ligaments and other localizations, surgical treatment can be limited, but one should be aware of a fairly high incidence of relapses and persistence of the disease .

In general, the incidence of recurrence of endometriosis after surgical treatment after 1-2 years is 15-21%, after 5 years – 36-47%, after 5-7 years – 50-55% and is highest in advanced endometriosis or in if it is impossible to remove infiltrative foci while preserving the organs of the reproductive system (nodular forms of adenomyosis, retrocervical endometriosis with partial or complete germination of the wall of the rectum or sigmoid colon, distal ureters, bladder). In these cases, it is advisable to qualify the clinical course as progression of the disease, and not relapse.

The frequency of recurrence of endometrioid ovarian cysts within 2-5 years after surgery varies from 12 to 15%. Reoperations on the ovary in women with infertility should be performed strictly according to indications, as there is evidence of a decrease in ovarian reserve after removal of endometrioid ovarian cysts. In this regard, in most cases, the treatment of endometriosis is complex and is carried out using various medications.

Non-selective NSAIDs inhibit the activity of both isoforms of the cyclooxygenase enzyme involved in the synthesis of prostaglandins, COX-1 and COX-2, although in the ectopic endometrium with endometriosis, an increase in the expression of only the last isoform is found.

A just-published meta-analysis of data on the effects of the most widely used NSAIDs (naproxen, ibuprofen, diclofenac, celecoxib, etoricoxib, rofecoxib and lumiracoxib) suggests an increased cardiovascular risk with their use. In 2004, data were published on the effectiveness of the selective COX-2 inhibitor rofecoxib in the treatment of moderate manifestations of dysmenorrhea, dyspareunia and chronic pelvic pain, and a year later it was withdrawn from clinical practice due to an increased risk of myocardial infarction and stroke with long-term use of the drug. in high doses. Thus, the efficacy and safety of the use of NSAIDs in long-term therapy of endometriosis is questionable, and the risk of long-term use of these drugs in high doses should be taken into account.

However, short-term treatment of pain associated with endometriosis with this class of drugs may be beneficial, including while waiting for symptom relief after targeted medical or surgical treatment is initiated.

Thus, non-steroidal anti-inflammatory drugs can be successfully used during therapy with GnRH-a, started in the luteal phase of the cycle or during menstruation, to relieve dysmenorrhea, which may increase during one cycle due to the initial effect of activation of the hypothalamic-pituitary- ovarian system observed on the background of these drugs.

Although hormonal therapy is not specific, its role in the complex treatment of patients with endometriosis can hardly be overestimated, since it is effective, safe enough, serves to prevent the recurrence and progression of the disease, and reduces the risk of repeat surgery.

The pathogenetic basis of hormonal therapy is temporary suppression of ovarian function with modeling of the state of “pseudo-menopause” using gonadotropin-releasing hormone (Gn-RH) agonists or Gn-RH antagonists (Gn-RH antagonists), aromatase inhibitors, or initiation of a pseudodecidualization state with subsequent atrophy foci of endometriosis due to exposure to progestogens (taken orally or intrauterine), selective progesterone receptor modulators or combined oral contraceptives.

There is a hypothesis that in some cases, the formation of endometrioid cysts can occur at the site of the ovulating follicle, so the suppression of ovulation, accompanied by the inhibition of its characteristic “pro-inflammatory cascade”, can serve as a measure to prevent the recurrence of the disease.

Hormone therapy can be used firstly as an empirical therapy in the treatment of patients with symptoms indicating a high probability of having endometriosis in the absence of cystic (ovarian) forms, and secondly as an adjuvant therapy for the prevention of relapse after laparoscopic confirmation endometriosis and / or removal of visible foci, endometrioid cyst capsule or removal of endometriosis with an infiltrative form of the disease (retrocervical localization, bladder, intestines).

Hormone therapy helps to preserve fertility, increase working capacity, social activity and quality of life of women. Currently, there are direct indications for the treatment of endometriosis with aGn-RH, antGn-RH and some progestogens.

Before prescribing hormonal therapy, it is necessary to conduct a generally accepted examination, including:

1. collection of family and personal history with an emphasis on identifying hereditary forms of thrombophilia;
2. gynecological examination;
3. instrumental and laboratory studies to assess the state of the cardiovascular system, biochemical parameters of the liver and kidneys to exclude contraindications;
4. transvaginal ultrasound, breast ultrasound or mammography depending on age and family risk, cervical smears for oncocytology.

Then the complex of these examinations should be repeated every 12 months. throughout the course of hormone therapy. According to the recommendations of the leading gynecological societies, combined oral contraceptives are the drugs of first choice (although without an approved indication) for the relief of endometriosis-related chronic pelvic pain in women who have no contraindications and are not planning a pregnancy at this point in time.