Obstet Gynecol Jul 15 Combination therapy with norethindrone acetate plus conjugated estrogens was more effective in building bone than norethindrone acetate alone.
Comment This was a small study of only 1 year's duration, and the differences in outcomes between the two groups were modest. Citation s : DiVasta AD et al.
Disclosures Disclosures for Robert W. October 20, Haymarket, Virginia. Academic Nephrologist. New Brunswick, New Jersey. Goserelin Zoladex Monthly or three-monthly injection Goserelin is embedded in a small biodegradable implant about the size of a grain of rice.
The implant is injected under the skin in the lower half of the abdomen once a month. Leuprorelin, Leuprolide Lupron Depot Monthly injection Leuprorelin comes as a monthly or, three-monthly, injection that is injected under the skin of the abdomen or arm, or sometimes into the buttock or thigh muscles.
Leuprorelin, Leuprolide Prostap SR Monthly injection Leuprorelin comes as a monthly or, three-monthly, injection that is injected under the skin of the abdomen or arm, or sometimes into the buttock or thigh muscles. Leuprorelin, Leuprolide Enantone Monthly injection Leuprorelin comes as a monthly or, three-monthly, injection that is injected under the skin of the abdomen or arm, or sometimes into the buttock or thigh muscles.
Leuprorelin, Leuprolide Lucrin Depot Monthly injection Leuprorelin comes as a monthly or, three-monthly, injection that is injected under the skin of the abdomen or arm, or sometimes into the buttock or thigh muscles.
Leuprorelin, Leuprolide Trenantone-Gyn Three-monthly injection Leuprorelin comes as a monthly or, three-monthly, injection that is injected under the skin of the abdomen or arm, or sometimes into the buttock or thigh muscles.
Naferelin Synarel Nasal Spray Nafarelin comes in a nasal spray pump. The recommended dosage is one spray of the pump into one nostril in the morning, and one spray into the other nostril in the evening every day. In a few women, the recommended dosage does not stop menstruation. If symptoms persist in these women, the dosage may be increased to one spray in both nostrils morning and night. Naferelin Synarella Nasal Spray Nafarelin comes in a nasal spray pump.
Triptorelin Decapeptyl SR Monthly and three-monthly injection Triptorelin comes as an injection that is injected under the skin or into the buttock muscle once a month or once every three months. Triptorelin Gonapeptyl Monthly injection Triptorelin comes as an injection that is injected under the skin or into the buttock muscle once a month or once every three months. If your gynaecologist does not prescribe add-back therapy, you might like to request it. Side effects Menopausal-type symptoms The side effects of the GnRH agonists are largely the result of the low levels of oestrogen in the body, so they are usually confined to the symptoms associated with the menopause.
The other common side effects are: insomnia decreased libido headaches mood swings vaginal dryness decreased breast size increased breast size acne muscle pains dizziness depression. The menopausal-type symptoms usually disappear soon after treatment ceases. Effectiveness for pain symptoms All the GnRH agonists work in the same way, so they are equally effective in regressing endometrial implants and reducing pelvic pain symptoms [1].
Effectiveness for infertility The GnRH agonists — like all the hormonal treatments for endometriosis — do not improve your chances of conceiving, without any reproductive techniques, so they should not be used as a treatment for infertility. Keeping track You should see your gynaecologist about 6—8 weeks after beginning your course of a GnRH agonist to discuss how the treatment is progressing. Pregnancy and breastfeeding GnRH agonists should not be used during pregnancy.
Interactions GnRH agonists may interact with other medicines. Recommendations on the use of GnRH in the management of endometriosis. In: Lunenfeld B ed. Efficacy of every-other-day administration of conugated equine estrogen and medroxyprogesterone acetate on gonadotropin-releasing hormone agonists treatment in women with endometriosis. Gynaecol Obstet Invest ; Prospective randomised double-blind trial of 3 versus 6 months of nafarelin therapy for endometriosis associated pelvic pain.
Fertil Steril ; However, this study had many limitations. The authors did not distinguish how the ovarian cyst was removed whether by cystectomy, drainage, or electrocautery , potentially clouding the results, as recurrence would be expected to be higher in those who did not have a complete cystectomy. The authors also did not specify the kind of hormonal treatment used combined oral contraceptives, progesterone only, or GnRH agonists or have a control group to compare to Using an oral progestin, dienogest, post-operatively is effective for suppression of recurrent endometriomas with a more favorable side effect profile than a GnRH agonist 12 , While both dienogest and a GnRH agonist might be equivalent in terms of disease recurrence 14 - 17 , side effect profiles differ.
In a prospective study of 52 patients who had surgery for ovarian endometriomas, post-operatively patients received either 6 months of a GnRH agonist followed by combined oral contraceptive, or 24 months of dienogest alone without a GnRH agonist Although both groups of women had decreases in their bone mineral, for those on dienogest, this decrease was not as severe —2. While this difference was not statistically significant, clinically it suggests that dienogest may be preferable to reduce unnecessary additional bone mineral density loss.
The use of GnRH agonists is controversial due to the significant side effects patients often experience. A case series of 28 patients after endometrioma removal who were treated with 6 months of GnRH agonist followed by placement of a levonorgestrel intrauterine device IUD concluded that this was an effective treatment for preventing endometrioma recurrence What is not mentioned however is that there was no comparison group for these patients all patients received treatment questioning our ability to make any positive conclusions.
GnRH antagonists have gained more attention in recent years with the approval of the oral GnRH antagonist, Elagolix, for treatment of endometriosis pain 2. This is a potentially promising therapy as demonstrated in two double-blind, randomized, controlled, clinical trials that showed improvement in endometriosis pain on both high and low doses of this medication Although patients still experienced hypoestrogenic side effects, with variations in dosing available, one can potentially mitigate these side effects with more control than GnRH agonists.
While a promising treatment for endometriosis pain in general, there is little to no data available on using GnRH antagonists in the post-operative setting to reduce endometriosis recurrence and further studies are needed. They recommend starting hormonal medication post-operatively to reduce the long-term endometriosis recurrence risk in women not desiring immediate pregnancy 4. While certain patient factors may influence choice of treatment, ESHRE favors using a levonorgestrel intrauterine system or a combined oral contraceptive for between 18 and 24 months post-operatively to reduce dysmenorrhea pain 4 , Every patient is different however, and other patient factors however, such as presence of an endometrioma, may instead lead to selection of a different medication.
It is critically important to offer patients the most beneficial treatments for reducing endometriosis recurrence, especially after undergoing surgery.
GnRH agonists have shown promise if used for a 6-month period with add back therapy post-operatively, however their hypo-estrogenic side effects can be very bothersome to patients and some patients are not able to tolerate them. It acts by binding to GnRH receptors in the pituitary gland. GnRH receptor agonists bind to the same receptors and initially cause an increase in estrogen production, which may temporarily worsen symptoms.
But because GnRH agonists bind much stronger to the receptors than GnRH does, the receptors soon become resistant to the hormone and no longer react to the stimulus.
As a consequence, estrogen synthesis by the ovaries is suppressed, and the menstrual cycle is suspended.
Estrogen is involved in the thickening of endometriotic tissue during the menstrual cycle. In endometriosis, the hormone also stimulates the growth of endometriotic lesions outside the uterus. By reducing estrogen levels, GnRH receptor agonists inhibit the growth of these lesions and endometriosis-associated symptoms.
Food and Drug Administration in
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