Let’s face it: managing your period is a hassle. There’s the cramping, the bloating, the bleeding, and the feeling a little cranky. Not to mention the need to remember to have tampons and ibuprofen on hand. There may also be the bad timing of a special occasion or a tropical vacation that complicates things further. But as aggravating as all this may be, for most women it’s just that: an aggravation, a nuisance that’s pretty easily dealt with.
But for about one in 10 women, their period, the week leading up to their period, and in some cases their entire month can be filled with severe cramps and pelvic pain that significantly affect their quality of life. A normal menstrual period for these women brings very painful cramps, chronic pelvic pain, and painful sex.
If you are one of the women who experiences these monthly symptoms, there is a good chance you suffer from endometriosis.
Here’s what endometriosis is
The lining of your uterus (the endometrium) builds up and sheds during your monthly menstrual cycle in response to your changing hormone levels. Endometriosis occurs when this tissue is found outside the uterus, typically on other structures in your pelvis including your ovaries. Although this endometrial tissue is in the wrong place, it acts exactly as if it were in the uterus where it belongs. So it, too, responds to changes in hormones. It builds up and then sheds and bleeds. This causes inflammation and sometimes scarring of the lining of your pelvis, which causes the chronic pain associated with endometriosis.
Who gets endometriosis and why?
There are two primary theories on how endometrial tissue gets outside the uterus:
Menstrual bleeding includes some backward flow up and through the fallopian tubes into the pelvis, and not just out through the vagina (retrograde menstruation).
Endometrial cells form outside of the uterus from developmental precursor cells.
Other factors that may contribute to the development of endometriosis include genetics (endometriosis tends to run in families) and exposure to environmental toxins, particularly those that affect hormones.
Estrogen fuels endometriosis
Levels of the hormones estrogen and progesterone go up and down during your menstrual cycle. But it seems that the rising estrogen levels typical of the first half of your cycle are mainly responsible for stimulating the growth (and worsening the symptoms) of endometriosis — estrogen helps endometriosis grow and attach to the lining of your pelvis, and it triggers inflammation.
On the other hand, progesterone counteracts the effects of estrogen and can sometimes be helpful in treating endometriosis.
Treating endometriosis
How your doctor will treat your endometriosis depends on the extent of your condition and whether or not you are planning on getting pregnant in the near future.
Here are the first-line options:
NSAIDs. Nonsteroidal anti-inflammatory drugs like ibuprofen block some of the inflammatory factors released by the endometriosis, but usually NSAIDs alone are not enough to relieve endometriosis pain.
Birth control pills. Frequently used to help treat endometriosis, the pill works by suppressing your ovulation and controlling your menstrual cycle. The progestin in birth control pills may help limit the growth of endometriosis.
Progestins. Progestin-only contraceptive methods can also be effective in treating endometriosis. The downside of this approach is the common side effects —irregular bleeding, mood swings, and weight gain. It is also thought that in many cases endometriosis is resistant to the effect of progestin.
And if those don’t work…
The next approach is to try turning off your body’s production of estrogen. Until recently the only type of medication available to do that was a GNRH agonist (Lupron and others). This medication is an injection given once a month or once every three months. By acting like a naturally occurring hormone in your brain, it turns off estrogen production in your ovaries. Without the monthly surge of estrogen, the endometriosis in your pelvis eventually burns out. But the drawbacks of using this medication include:
symptoms may get worse during the first few weeks of treatment before the medication starts working
significant menopause symptoms like hot flashes and vaginal dryness
needing an injection every month or every few months.
Probably the biggest disadvantage of using these medications is that the estrogen suppression is all or nothing. You can’t turn down the estrogen just a little bit to shrink the endometriosis but avoid menopause-like discomforts.
The good news: A promising new option for treating endometriosis
In May, the New England Journal of Medicine published a study showing promising results for a new medication. Elagolix is a GNRH antagonist that can dial down estrogen production to varying degrees. Although Elagolix still has the significant side effects of a low estrogen state, it is thought that they may not be as severe as when estrogen is completely shut off. And it is taken as a pill, once a day, rather than by injection.
The article reports data from pre-approval clinical trials showing that women treated with both a lower and a higher dose of Elagolix showed significant reductions in menstrual cramps and non-period related pelvic pain at three months compared to women who received a placebo medication. In addition, women taking the higher dose reduced their need to use pain medications to treat their symptoms.
Elagolix has been submitted for FDA approval. If approved, it will offer women with endometriosis a new treatment option with fewer side effects and greater convenience.
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