Hormonal Therapy Options for Treating Endometriosis

Hormonal Therapy Options for Treating Endometriosis:

A Guide for Teens

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You may already know about the different medical options on how to best manage endometriosis. These beliefs are based on scientific research and the fact that there is no available cure for endometriosis at this time. Therefore, treatment is aimed at controlling pain and preventing the endometriosis from getting worse. This guide was created to help you understand the different choices of medical therapy for the treatment of endometriosis, as well as the benefits and possibly side effects that are most commonly reported. Since most birth control options are also hormone medicines, you may already be familiar with some of the types of medicines that are discussed in this guide. It is our hope that the following information will help you make a good decision about your treatment plan. As with any hormonal medicines, if you have certain medical conditions such as a history of blood clots, hormonal therapy may not be an option for you. Be sure to talk with your health care provider about your concerns.

Hormonal Therapy with Combined Estrogen and Progestin

Oral Contraceptive Pills (OCPs)
Oral contraceptive pills or "birth control pills" contain the hormones estrogen and progesterone and are taken in a "cyclic" way. There are 28 pills in each package, usually 21 with hormones and 7 "reminder pills." When you finish the last row of pills, you will start your next pill pack. The oral contraceptive pills work by temporarily turning off your ovaries. This is a common treatment for dysmenorrhea (painful periods) and other pelvic pain that occurs with endometriosis. Although the goal is to control the pain from endometriosis, it is possible for some girls to have pain with their periods.

The Patch

The patch is a new type of hormone therapy that looks like a square Band-Aid. It contains hormone medicine similar to birth control pills and is worn on your skin. Like birth control pills, the patch may be prescribed for irregular periods, menstrual cramps and endometriosis. Each hormone patch lasts one week. (You change it every week for 3 weeks then you have a "patch-free" week. You will get your period during this week. Some girls and women prefer the patch instead of oral contraceptive pills (OCPs) because you don’t need to remember to take it everyday.

The Vaginal Ring

The vaginal ring is a small, thin flexible ring that fits inside the vagina. Once in place it releases a combination of estrogen and progestin (hormones). Similar to oral contraceptives and the patch, the vaginal ring may be used to treat symptoms of endometriosis by controlling your menstrual cycle. When you use this method of cyclic hormone therapy, you remove the ring after the third week; leave it out for one week than replace it after 7 "ring free" days. Most girls and women will get their period during the "ring free" week. Some girls and women prefer the vaginal ring because it is worn inside the vagina where it is not visible. When properly inserted, neither you nor anyone else can tell that it’s in your vagina. Some girls and women prefer the vaginal ring instead of oral contraceptive pills (OCPs), because you don’t need to remember to take it every day. The vaginal ring is effective for 3 weeks at a time.

Benefits:

Combined estrogen and progestin hormonal therapy may decrease, and in some cases stop pain that occurs with endometriosis.
Most girls and women report that they have a lighter menstrual flow, their periods are shorter, and they know when to expect their period.

Possible Side Effects:

Some girls and women have reported side effects such as spotting or irregular bleeding, breast tenderness, mood swings, headaches, nausea, cramps, bloating and or weight gain.
Spotting (break-through bleeding) and irregular bleeding can be a common side effect. Bleeding may be as light as spotting, requiring just a panty shield, or as heavy as a regular period. Spotting can last for a few days as your body gets used to the medicine or last as long as you are on this hormone therapy.
Some girls who use the hormone patch may experience skin irritation where the patch is worn.
Some girls who use the vaginal ring may experience vaginal irritation.
Some girls may not have relief from their endometriosis pain.

Progesterone-Based Hormonal Therapy

Medroxyprogesterone acetate

Medroxyprogesterone acetate is a type of medication that contains the hormone progesterone. Your health care provider gives it as an injection once every 3 months. Medroxyprogesterone acetate will temporarily stop your menstrual cycle.

Norethindrone acetate

Norethindrone acetate (Aygestin) contains only progesterone and it is taken by mouth every day. It is a type of hormone medicine that is often prescribed for patients that cannot take hormone medication with estrogen in it.

Benefits:

Progesterone based hormone therapies can be effective in treating symptoms of endometriosis.

Possible Side Effects:

Some research studies suggest that adolescent girls may have lower bone density and have a higher risk of osteoporosis (brittle bones) if they take Progesterone based hormone medicine for a long time. Your doctor may also prescribe estrogen if you are on this medicine for more than 6 months for endometriosis.
Some girls and women may experience breast tenderness, irregular bleeding, mood swings, nausea, bloating, weight gain and/or hair thinning.
Some girls may not have relief from their endometriosis pain.

Hormonal Therapy with GnRH agonists (Gonadotropin Releasing Hormone agonists)

This type of hormone works by temporarily turning off your pituitary gland and your ovaries. This therapy makes your ovaries think that you are pre-pubertal (the time before puberty) because your ovaries stop making estrogen and progesterone. Lack of estrogen circulating in your body causes your periods to stop. Since all of the GnRH agonists lower estrogen levels, the possible side effects for all of the medicines in this group are the same and are often associated with menopause-like symptoms. GnRH agonists are approved by the Food and Drug Administration (FDA) for 6 months of treatment.

While taking GnRH agonists, it is important to get enough calcium in your diet or by taking calcium supplements. Your body needs 1300mg of Calcium and 400 IU of Vitamin D every day.

Depot-leuprolide acetate

Depot-leuprolide acetate is one type of GnRH agonist that is given as an intramuscular (in the muscle) injection. It can be given as a once a month injection (white container) or once every 3 months (blue container.) As you might expect, the monthly injection works for about one month and the three-month dose works for about 3 months.

Nafarelin acetate

Nafarelin acetate is another type of GnRH agonist (hormone medicine) that is in the form of a nasal spray. The recommended dose is one puff in one nostril in the morning, then another puff in the other nostril at nighttime.

Benefits:

GnRH agonists work by lowering your estrogen levels. Low levels of estrogen prevent your body from ovulating (making eggs). This means that you will not ovulate (not make eggs) and you will not have your period.
This medicine can work very well in decreasing endometriosis pain by stopping your period.

Possible Side Effects:

If you are on this medicine for longer than 6 months, you may be at risk of developing osteoporosis (brittle bones).
Side effects may include hot flashes, mood swings, vaginal dryness, bone and joint aches, hair loss, decreased interest in sexual relations, and possible short-term memory loss but stop after the medication is discontinued and your menstrual cycle returns.
Some girls may not have relief from their endometriosis pain.

GnRH agonists and Hormonal Add-back Therapy

The combination of GnRH agonists and Hormonal Add-Back Therapy is usually prescribed when other hormonal medicines do not work in relieving pain associated with endometriosis. Many girls feel very well on GnRH agonists, but since the FDA (Food and Drug Administration) has only approved it for six months of treatment at a time, it is not okay to stay on this treatment for longer than 6 months without taking a small amount of "add-back therapy." A new way of keeping young women on this medicine for longer periods of time is to add a small amount of estrogen and progesterone or progesterone alone. This is called "add-back" therapy.

Benefits:

Since estrogen is important to keep your bones healthy, low levels of estrogen can lower your bone density putting you at risk of osteoporosis (thinning of your bones). The goal of “add-back” therapy is to give you back just enough hormones to protect your bones and control any unwanted side effects such as hot flashes and vaginal dryness that are common when taking GnRH agonist therapy alone.
In many cases, teens and women may be able to stay on this treatment longer than six months as long as their doctor follows them closely. Bone density can be followed by a simple test called DEXA that is similar to an x-ray (with much less radiation).

DEXA Machine

The DEXA test measures how dense or thick your bones are and if your bones are thinning too early. The test doesn’t hurt and takes only about 15-20 minutes. You lie on your back with a pillow under your knees and your arms next to your body. A machine shaped like an upside down “L” will slowly move back and forth over your stomach area to measure the bone density of your spine and hip (the machine is about 12 inches away from your body as it scans). While it is important to stay fairly still, you can move, breathe, cough, and talk during this test.

Possible Side Effects:

Some girls and women may continue to have mild side effects associated with "menopause-like" symptoms such as hot flashes, mood swings, vaginal dryness, bone and joint aches, hair loss, decreased interest in sexual relations, and possible short-term memory loss even though estrogen and progesterone have been added.
Since every girl and women responds to hormone therapy differently, your health care provider may need to change or adjust the amount or type of "add-back" medicine you are taking.
Endometriosis symptoms may return when "add-back" therapy is started.

Whether you chose to take hormonal therapy alone or hormonal therapy after surgery, remember all medicine affects each person differently. If you have side effects, talk with your doctor about choosing a new type of hormonal therapy; however, it usually takes about 2-3 menstrual cycles to see an improvement in symptoms and for your body to get used to any medicine.

Deciding what treatment is best for you may take some time. Talk to your health care provider about any concerns or questions you might have. It may also be helpful to talk with other teens with endometriosis that have used different treatments. In the meantime, you can help your body feel better by eating well and getting plenty of rest and exercise!

Written by the Center for Young Women's Health Staff

Updated 6/14/2005

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