Endometriosis: Two New Options for Pain Relief

by Dr. Isadore Rosenfeld

More than 5.5 million American girls and women of reproductive age have endometriosis, a disorder in which tissue that normally lines the cavity of the uterus (the endometrium) appears in other locations, where it has no right to be. Some research indicates that the disorder affects more Asians than Caucasians or African Americans.

In a woman with endometriosis, endometrial tissue has most commonly migrated to the ovaries (in 75 percent of cases), or to the fallopian tubes (along which eggs travel from the ovaries to the uterus), or elsewhere in the pelvis. But it is sometimes found between the rectum and vagina or in the rectum itself, in the appendix, in the urinary bladder, and occasionally in the stomach. It has even very rarely been present in the gallbladder, spleen, liver, and lungs. Symptoms (mainly pain, bleeding, and infertility) usually become apparent soon after the onset of menstrual periods, and the disorder comes and goes until menopause.

The wandering endometrial tissue, wherever it happens to end up and by whatever route it got there, sometimes behaves as if it were still in the uterus. In other words, it can menstruate! That's why symptoms of endometriosis are usually intermittent, and their timing is often related to the normal menstrual period. No two women with endometriosis have exactly the same complaint because their symptoms depend on the location of the misplaced uterine tissue. Unlike normal menstruating tissue in the uterus, wandering endometrial tissue has no way of being shed as it is from the uterus every month. It remains in its location, where it eventually forms scar tissue and adhesions that irritate the area, causing symptoms not only during the menstrual period but all month long.

Why endometrial tissue wanders in this way is not fully understood. There may be a genetic basis to it. If your sister or mother has it, there's a greater chance that you will, too. Many gynecologists believe, however, that this disorder is mainly due to an abnormal immune system that allows these cells not only to migrate from the uterus but also to survive where they don't belong.

There is no cure for endometriosis, but there are ways to reduce the pain it causes, restore fertility, and shrink the size of the "lost" tissue. However, the best long-term treatment option is to remove the offending tissue if possible.

Managing endometriosis first and foremost involves pain relief. This is best done with aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and acetaminophen. The sooner you start taking them when you have pain, the more effective they are. If the pain is very severe, you may need a prescription-strength painkiller.

Any drug or hormone (such as progestin) that stops menstrual periods will also ease the symptoms of endometriosis. This, however, is not a satisfactory long-term solution for many women. Progestin is not as popular as it once was, because the high doses required result in bloating, weight gain, depression, and irregular vaginal bleeding. It may also sometimes cause a prolonged and negative effect on ovarian function even after it has been stopped.

Other popular treatments are the gonadotropin-releasing hormone (GnRH) agonists that decrease the brain's production of luteinizing hormones (LH) and follicle-stimulating hormones (FSH). (LH and FSH stimulate the formation of estrogen, the hormone that promotes growth of endometrial tissue.) GnRH agonists take about a month to work and are available as a nasal spray or as a monthly injection. Pregnant women should not use them.

Here's What's New

A team of Italian gynecologists in Milan treated 50 women with endometriosis by having them take oral contraceptives continuously without the usual 1-week pause. This ensured that there were no menstrual periods during which pain could occur. After 2 years, 80 percent of the women reported that they were satisfied with the treatment and that it had resulted in less pain. According to the president-elect of the American Society of Reproductive Medicine, "if women suffering from endometriosis are not ready to become pregnant, continuous oral contraceptive use is one of the better ways to manage pain. The effect of the Pill is reversible, so future fertility is possible, and if side effects (of the Pill) are more troublesome than warranted by pain relief, it can be easily discontinued. For these reasons, oral contraceptives are an excellent option" for the management of the symptoms of endometriosis.

There is no downside to taking the Pill continuously to suppress menstruation. The FDA has just approved Seasonale (ethinyl estradiol/levenorgestrel), a contraceptive pill that allows women to have just four menstrual periods a year.

Another promising approach to reducing the pain of endometriosis is one of the aromatase inhibitors used in the treatment of advanced breast cancer. In a small study done at Northwestern University Feinberg School of Medicine in Chicago, researchers found that 10 premenopausal women with painful endometriosis who had previously not responded to any other therapy experienced dramatic improvement in their symptoms after taking an aromatase inhibitor. In this case, the drug used was Femara (letrozole), one of several in this class. There were no significant side effects or complications during a 6-month period.

The Bottom Line

If you are troubled by ongoing pain, bleeding, and cramps from endometriosis, and you cannot be treated surgically, you should consider going on the Pill and taking it nonstop -- that is, without the customary week off once a month. When you want to begin trying to have a baby, you simply stop the Pill.

Another alternative for controlling the pain of endometriosis that's worth exploring with your doctor is an aromatase inhibitor called Femara. Results of a small study of premenopausal women with pain not responsive to other medication suggest that it's worth a try. Side effects and complications from its use appear to be minimal.

Dr. Isadore Rosenfeld is the best-selling author of nine books, including Live Now, Age Later and Dr. Rosenfeld's Guide to Alternative Medicine. He is a distinguished member of the faculty at New York-Presbyterian Hospital/Weill Medical College of Cornell University and attending physician at New York-Presbyterian Hospital and Memorial Sloan-Kettering Cancer Center. Dr. Rosenfeld can be seen every Sunday morning on his popular show Sunday Housecall on Fox News Channel. He is the health editor and a regular columnist for Parade magazine.

Copyright © Dr. Isadore Rosenfeld. Permission to republish granted to Pregnancy.org, LLC.