Progestagens can be used in different forms: orally, as a 3-monthly injection or a levonorgestrel-releasing intrauterine system. Different types of progestagens are medroxyprogesterone acetate (MPA), dienogest, cyproterone acetate or danazol. Progestagens are also used as contraceptives, but they only contain progesterone, not estrogen. Anti-progestagens (gestrinone) have a similar method of action. Progestagens are relatively inexpensive.

The different types of progestagens and anti-progestagens have different side effects. Doctors are recommended to take the side effects into account when prescribing this type of medication and discuss them with the patient. Patients are recommended to report any side effects with their doctor and discuss their options.

Progestagens / Anti Progestogens

Progestagens are a synthetic form of a natural hormone called progesterone. This treatment might be recommended for women who do not get pain relief from or who cannot take hormonal birth control that contains oestrogen (such as smokers). Progestagens can be used in different forms: orally daily, as a 3-monthly injection or a levonorgestrel-releasing intrauterine system. Different types of progestagens are medroxyprogesterone acetate (MPA), dienogest, cyproterone acetate or danazol. Anti-progestagens (gestrinone) have a similar method of action. In Ireland, Provera, Depo Provera and Cerazette are brand names of Progestagens.

The different types of progestagens and anti-progestagens have different side effects. It is important to read up on the side effects and discuss with your doctor before starting treatment.

The “Mirena” and other IUS

A levonorgestrel-releasing intrauterine system is a small device that is inserted in the uterus and releases low levels of progesterone. A levonorgestrel-releasing intrauterine system is frequently used for contraception; it has limited side effects. In women with endometriosis, the levonorgestrel-releasing intrauterine system is an option for reducing symptoms of pain associated with menstruation. The IUS can take up to 8 weeks to settle down, during this time pain and bleeding may be exacerbated. In some women the IUS can stop periods completely, reducing the pain and symptoms of endometriosis. In other women, the IUS is not well tolerated and is removed.

The ESHRE Guidelines 2013 recommended that “There is sufficient evidence on the effectiveness of progestagens and anti-progestagens, including the levonorgestrel-releasing intrauterine system, in reducing pain in women with endometriosis. The ESHRE group stresses that clinicians should look at side-effect profiles, to tailor the medical treatment and improve the quality of life of the woman.

Regarding the use of danazol for treatment of endometriosis-associated pain, the ESHRE group strongly believes that danazol should not be used if any other medical therapy is available, due to its severe side effects (acne, oedema, vaginal spotting, weight gain, muscle cramps)”

Discuss this option and the side effects with your doctor. Your GP and Gynaecologist can prescribe this type of treatment in Ireland.

GnRH agonists induce a very low estrogen level by stopping the follicular growth in the ovary completely. GnRH agonists can be taken intranasal, or through subcutaneous injection as a depot working either one or three months. Some of the most common GnRH agonists are nafarelin, leuprolide, buserelin, goserelin and triptorelin. GnRH agonists have more side effects than oral contraceptives and progestagens and are more expensive.

The side effects of GnRH agonists are related to the low level of estrogens and are comparable to the consequences of the menopausal status.

These so-called hypo-estrogenic symptoms are hot flushes and night sweats, vaginal dryness and related pain during intercourse, and influences on the mental health up to depressive feelings. In the long term GnRH agonists are associated with osteoporosis. To reduce these symptoms, clinicians are recommended to prescribe hormonal add-back therapy as soon as GnRH agonists are started. Hormonal add back means adding a combination of estrogens and progesterone (oral contraceptives).

This add back therapy takes away the side effects while the therapeutic effect is maintained. Since adolescents and young women up to the age of 23 have not reached their optimal bone density, it is advisable not to use GnRH agonists in these women.

Some of the most common GnRH agonists/antagonists are nafarelin, leuprolide, buserelin, goserelin and triptorelin. GnRH agonists/antagonists have more side effects than oral contraceptives and progestagens and are more expensive. They are prescribed on the “High Tech” drug scheme in Ireland. Discuss this option and the side effects with your doctor. Your Gynaecologist can prescribe this type of treatment in Ireland. Brand names include Decapeptyl, Zoladex, Prostap and Synarel.

GnRH agonists/antagonists are not used if you are trying to become pregnant.

GnRH agonists, with and without add-back therapy, are considered effective in the relief of endometriosis-associated pain during their us. Evidence is limited regarding dosage or duration of treatment. No specific GnRHa can be recommended over another in relieving endometriosis-associated pain.

Discuss this option and the side effects with your doctor. Your Gynaecologist can prescribe this type of treatment in Ireland.

Aromatase inhibitors stop an enzyme called aromatase that is needed in the production of oestrogens in several cells of the body. The result is a very low oestrogen level. These drugs have only recently been used in endometriosis and not well studied yet. They have proven efficacy for other conditions.

Due to the side effects associated with low oestrogen (vaginal dryness, hot flushes, diminished bone mineral density), aromatase inhibitors should only be prescribed to those in severe pain after trying all other options of medical and surgical treatment. Examples of aromatase inhibitors include letrozole and anastrozole. They are prescribed in Ireland under the brand names Femara and Arimidex.

All evidence is based on studies in women with rectovaginal endometriosis or women that have ongoing severe pain despite previous surgical and medical treatment. The EHSRE recommendations state that aromatase inhibitors should only be prescribed to women after all other options for medical or surgical treatment are exhausted.

Aromatase inhibitors can be prescribed off label by your gynaecologist in Ireland if this medication is suitable for you. Discuss this option and the side effects with your doctor. Your Gynaecologist can prescribe this type of treatment in Ireland.