New treatments target painful fertility sapping endometriosis

Gynecologists know what to look for. “In the mature form, the endometriotic implants look like little powdered burns. They’re little, dark and speckled. But the gynecologist can also recognize early lesions, which tend to be more inflammatory and flame-like,” Soper said.

Step three can involve giving the woman birth control pills continuously to keep her from having periods. Sometimes that solves the pain problem.

But if that doesn’t work, or the woman wants to get pregnant, it’s on to step four. “You can use progestins without estrogen,” Soper said. “And then there is therapy with Lupron or GNRH agonists, which are drugs that cause a medically-induced menopause that’s reversible.”

The woman stops having periods and her endometriosis gets better, but she also has hot flashes and other symptoms she wouldn’t normally feel until much later in life. “At the age of 25 or 30, that’s not exactly what you want to do,” Soper said. “But there’s an answer to that. It’s called add-back therapy.”  

In add-back therapy, the doctor gives the woman the hormone leuprolide, sold as Lupron, to ease her pain. Once it takes effect, the woman can take a low level of hormones to manage symptoms such as hot flashes and vaginal dryness.

Soper said the doctor may also try aromatase inhibitors, which are often given to women with breast cancer to lower their estrogen level.

New endometriosis treatment options

“The newer drugs fall into two classes,” Soper said. “One is GNRH antagonists, which includes elagolix, also known as Orilissa.” The advantage over Lupron is that instead of initially feeling worse, as she would on Lupron, the relief is almost immediate. “And it’s a pill instead of shot,” Soper said.

But elagolix still causes reversible menopause. However, “the side effects end up being well worth the pain relief,” Soper said. 

“The other class of drugs that are new for endometriosis are the selective progesterone receptor modulators, or SPRM.” They target progesterone, a hormone that helps regulate a woman’s menstrual cycle and maintain pregnancy but is also linked to period-related pain. 

“One kind of cool thing about SPRMs is that women on the drug say, ‘Man, I feel really good.’ I think it’s because they’re not having PMS at all. That hasn’t been studied for this, but there might be an opportunity for that down the road.”

One SPRM, ulipristal, has been tested as a treatment for endometriosis and uterine fibroids in Europe and Canada but has not been approved for use in the U.S. “The beauty of the SPRMs is side effects like hot flashes are much less because you don’t lower estrogen levels as much as you do with elagolix or Lupron."

Soper, who leads the gynecology program at MUSC Women’s Health, recently saw his team ranked No. 18 in the country out of almost 5,000 medical centers by U.S. News & World Report. “We have a team of superb gynecologists who know how to make the diagnosis and treat patients medically. We have superb surgeons, including robotic surgeons, who can do the difficult dissections that are associated with scar tissue that’s associated with endometriosis,” Soper said.

“We’re doing research on the newest agents that appear to be highly effective and have less side effects than conventional therapy for endometriosis. Endometriosis interferes with the intimacy that’s so important between couples that has downstream effects. Women need good initial therapy and a gynecologist who’s a good listener to really understand her symptoms.”