Expert: DANIL HAMMOUDI.MD - 8/23/2004

Question
After proving that I have remaining and/or growing endometriosis via a cat scan in ER, I have been advised to get a referral to a GYN and to expect to be put on Lupron.  This brings up several questions but first..I recently quit taking my prescribed estrogen and was trying Phyto-Estrogen(by Soloray).  I did this because I love the outdoors..but hate the skin spots and figured it was worth a shot.  With this, I have been able to go out with sunscreen but not have to completely avoid the sun.  My mood had seemed to be in higher spirits, less depressed, although the hot flashes have sky rocketed.

With Lupron, am I going to get these spots back and what other side effects should I expect.  How long will I take this and is this the only/best solution.  If this is temporary, what's nest?

Thanks for anything you can tell me.  I am currently waiting for a return call from a possible GYN and would like to be somewhat prepared.

Answer
if I understood you had an hysterectomy for endometriosis and the endometriosis expend else where? am I right?
I might include below some input on pregnancy risks siince I am not sure if you had an hysterectomy, I think you had .


let's start with general info then specific with the treatment proposed:
The treatment options for endometriosis include:
Observation with no medical intervention
Hormone treatment
Surgery
Combined treatment
Complementary therapies.
Observation with no medical intervention
In mild cases of endometriosis, it may be possible to simply monitor the condition with regular visits to your doctor or gynaecologist. Antiprostaglandin medications (nonsteroidal anti-inflammatory drugs such as ibuprofen and mefenamic acid) can help to control any associated pain. If symptoms progress, talk over the medical options with your health care provider before making a final decision.

Hormone treatment
These treatments can have side effects, so be well informed about them before you and your doctor decide on your treatment. The uterine lining is prompted by the hormone oestrogen to thicken in preparation for possible pregnancy. During menstruation, the hormone progesterone causes the plump uterine lining to shed. The misplaced endometrial cells in other areas of the body also respond to oestrogen and progesterone. Hormone therapy can sometimes be an effective way to manage the symptoms of endometriosis. Options include:
Danazol - this mild form of the male hormone testosterone reduces the amount of oestrogen produced by the ovaries to around the same level as occurs during menopause. Without oestrogen, the stray endometrial cells can't grow and, therefore, shrink and disappear during the treatment. The side effects of Danazol include weight gain, bloating, fluid retention, acne, smaller breasts, increase in muscle mass, increased facial and body hair, muscle cramps, mood swings, voice deepening and clitoral enlargement. Danazol can also cause gastrointestinal upsets, depression and liver disease.
Gestrinone - is a synthetic hormone that causes the endometriosis to become inactive and waste away. Side effects of gestrinone include weight gain, acne, depression, mood swings, hot flushes and loss of libido (sex drive).
Dydrogesterone - a synthesised version of the hormone progesterone, which helps to dry up the stray endometrial cells. Ovulation may still occur. Side effects of dydrogesterone can include depression, tender breasts, weight gain, fatigue, nausea, headaches and dizziness.
Medroxyprogesterone acetate - another synthesised version of the hormone progesterone. Most women taking Medroxyprogesterone acetate will stop ovulating and menstruating. Other side effects include weight gain, bloating, irregular vaginal bleeding, depression, sweating, headaches, acne, nausea, fatigue and tender breasts.
GnRH agonists - gonadotrophin-releasing hormones help to govern the menstrual cycle. GnRH agonists are drugs that stop the ovaries from producing as much oestrogen by reducing the hormones produced by the pituitary gland (follicle stimulating hormone and luteinising hormone). Without oestrogen, the misplaced endometrial cells are unable to grow. Side effects of GnRH agonists include menopausal symptoms such as thinning of the bones, hot flushes, dry vagina, headaches, depression, loss of libido and night sweats. These symptoms can be relieved, while still maintaining the benefit of the treatment, by adding back oestrogen and progesterone.
The oral contraceptive pill - the Pill is frequently used to achieve long term suppression of endometriosis. It can be used to stop the disease progressing in women with mild disease or to stop the disease from recurring following surgical or hormonal treatment.
Surgery
The different types of surgery include:
Operative laparoscopy - a slender tube is inserted into the abdominal cavity via a small incision. Endometrial implants, cysts and adhesions are then removed by either cutting or cauterising them. Some doctors can perform surgery, including the removal of the ovaries or removal of endometriosis from the bowel, laparoscopically.
Hysterectomy - the uterus is removed, along with endometrial implants, cysts and adhesions. In some cases, the fallopian tubes and ovaries will also be removed. Unfortunately, hysterectomy does not always cure endometriosis.
Combined treatment
In some cases, a woman will benefit from undergoing hormone therapy as well as surgery. Hormone therapy may be offered before or after the surgery, depending on the circumstances.

Complementary therapies
Some women find complementary therapies to be helpful. Always tell your doctor about the kinds of complementary therapies you are using or considering. Options include:
Acupuncture
Chinese medicine
Herbal therapy
Homeopathy.
Pregnancy is not a cure
Some people believe that endometriosis can be cured by pregnancy. This isn't the case. The symptoms may improve for some women, but worsen in others. For those women who experience an end to all symptoms during pregnancy, the relief may only be short lived. Unfortunately, for some women, the endometriosis will recur.


Things to remember
Endometriosis is the growth of endometrial tissue in places outside the uterus.
Surgery is regarded as the most effective treatment. The symptoms can sometimes be managed with hormone therapy, although unwanted side effects are possible.
Contrary to popular belief, pregnancy is not a cure for endometriosis

Endometriosis - causes and risk factors
 The tissue that lines the inside of the uterus is called the endometrium. Endometriosis is the growth of endometrial tissue in places outside the uterus, such as the ovaries, uterus, bowel and lining of the pelvic cavity.

Symptoms
The symptoms of endometriosis include:

Painful periods
Painful intercourse
Pelvic pain
Ovulation pain
Pain in the lower back and thighs
Bowel symptoms
Bladder symptoms
Reduced fertility.
Usually, endometriosis causes pain around the time of the period, but some women experience almost constant pain. The causes of endometriosis remain unknown, but researchers have uncovered a number of possible causes and risk factors.

Stray endometrial cells respond to hormones
The endometrium responds to the sex hormones oestrogen and progesterone. In women with endometriosis, the stray endometrial cells in the pelvic cavity also respond to these hormones.

During ovulation, oestrogen prompts the uterine lining - and the misplaced endometrial cells - to thicken. However, the misplaced endometrial cells cannot leave the body via menstruation; they simply bleed a little, causing inflammation and pain, and then heal. Over time, this may create scar tissue. Occasionally, affected organs, such as the ovaries and bowel, may stick together. This can cause chronic pain and bowel symptoms. Sometimes, it can cause fertility problems if the scar tissue (adhesions) stops the released egg from getting to the fallopian tube.

Genetic susceptibility
Recent studies indicate that some women are genetically predisposed to developing endometriosis. According to researchers from the University of Queensland, endometriosis runs in families, which means the genetic susceptibility is inherited.

Australian researchers have found that women who have a sister with the disease are 2.3 times more likely to have the disease than women in the general community. The increased likelihood of developing the disease is not just confined to the daughters and sisters of women with the disease but also affects their cousins.

Possible causes
Some of the theories on what causes endometriosis include:
Retrograde menstruation
Immune system malfunction
Genetic factors.
Retrograde menstruation
Retrograde menstruation is also known as 'backward menstruation'. The lining of the uterus is shed during the period. In almost all women, some of the menstrual fluid flows backwards into the fallopian tubes instead of leaving the body through the vagina.

Since the fallopian tubes are open-ended (they are not joined to the ovaries, but open nearby), menstrual fluid can drip into the pelvic cavity. It is suspected that in women who experience endometriosis, the endometrial tissue contained in the menstrual fluid sticks to whatever structures it lands on (such as the ovaries) and starts to grow.

Immune system malfunction
Retrograde menstruation occurs in almost all women, but only 3-10 per cent of menstruating women develop endometriosis. One theory suggests that the immune systems of some women allow endometriosis to develop by failing to control or stop the growth of endometrial tissue outside the uterus.

The genetic factor
It seems that genetic susceptibility plays a significant role in the development of endometriosis - but how? Some researchers suspect that some families carry faulty genes that allow abnormal cells to survive and grow in the pelvic cavity.

Risk factors
Apart from genetic susceptibility, some of the suspected risk factors include:
Exposure to toxins - persistent environmental pollutants, such as dioxins, are suspected of contributing to the development of endometriosis. Animal experiments have indicated such an effect, but at levels of exposure higher than those currently seen in humans.
Menstrual cycle factors - some evidence suggests that women with endometriosis are more likely to have started their periods at an early age. Other factors related to the menstrual cycle that may predispose a woman to endometriosis include short menstrual cycles (less than 27 days) and long periods (more than one week).


A for lupron [ Leuprolide acetate]:GnRH-agonist medication works by suppressing estrogen production.Lupron suppresses shedding of the endometrium (lining of the uterus) during menstruation and is used to treat endometriosis.Two forms of Lupron--Lupron Depot 3.75 and Lupron Depot 11.25--are prescribed to relieve the pain of endometriosis and shrink the growths. (The hormonal medication norethindrone acetate is often added to the regimen.) Three other forms of Lupron--Lupron Depot 7.5, Lupron Depot 22.5, and Lupron Depot 30--are prescribed to relieve the symptoms of advanced prostate cancer.

The first two forms of Lupron are also used before surgery, along with iron, to treat anemia caused by fibroids (tumors) in the uterus when iron alone is not effective. Some doctors also prescribe Lupron for infertility and for early puberty.

you might experience the following due to low estrogen from the drug:
 hot flashes, headaches, mood swings, weight gain, muscle and bone pain, sleep disorder, bone calcium loss and memory difficulties.Excessive pain associated with menstruation; continuing vaginal bleeding or white discharge; infertility; bone, muscle, or joint pain; changes in skin color of face; fainting; fast or irregular breathing; numbness or tingling of hands or feet; puffiness or swelling of the eyelids or around the eyes; shortness of breath; skin rash, hives, and/or itching; sudden, severe
decrease in blood pressure and collapse; tightness in chest or wheezing; troubled breathing; anxiety; deepening of voice; increased hair growth; mental depression; mood changes; nervousness;Anxiety, appetite changes, breast tenderness or pain, depression, fluid retention, development of male characteristics, dizziness, general pain, inflammation of the vagina (vaginitis), insomnia or other sleep disorders, joint pain, memory problems, nausea and vomiting, nervousness, skin reactions, stomach or intestinal disorders, unusual burning or prickling sensation of the skin, weakness, weight gain or loss

Less common side effects may include:
Agitation, allergic reactions, blood clots, bruising, delusions, difficult or painful urination, dry mouth, ear pain, eye problems, facial swelling, fainting, hair loss, hair problems, palpitations (throbbing heartbeat), rapid heartbeat, reactions at the injection site, secretion of milk, sore throat, thirst

Additional side effects you may experience if you are taking Lupron for anemia include:
Body odor, flu symptoms, nail problems, nasal irritation, pinkeye, taste disorders

These problems can all be solved by combining the use of GnRH-agonists with a combination of low-dose estrogen and progesterone. This approach is called add-back therapy. Add-back therapy usually prevents all the side effects mentioned above, while not diminishing the treatment's effectiveness at alleviating endometriosis symptoms.

Depo-Lupron is approved for six months of use. Unfortunately, once the medication is stopped at the end of six months, symptoms recur rapidly. An additional benefit of add-back therapy is that it enables safe use of these medications for longer periods than six months. In fact, many women have been safely treated this way for many years with long-term relief of symptoms



During the early phase of therapy, gonadotropins and sex steroids rise above baseline because of the natural stimulatory effect of the drug. Therefore, an increase in clinical signs and symptoms may be observed
Response to leuprolide acetate should be monitored 1-2 months after the start of therapy with a GnRH stimulation test and sex steroid levels. Measurement of bone age for advancement should be done every 6-12 months.

Sex steroids may increase or rise above prepubertal levels if the dose is inadequate
Once a therapeutic dose has been established, gonadotropin and sex steroid levels will decline to prepubertal levels.
Prior to starting therapy with LUPRON Injection, the parent or guardian must be aware of the importance of continuous therapy. Adherence to daily drug administration schedules must be accepted if therapy is to be successful. Irregular dosing could restart the maturation process.

· During the first 2 months of therapy, a female may experience menses or spotting. If bleeding continues beyond the second month, notify the physician.

· Any irritation at the injection site should be reported to the physician immediately. If the child experiences an allergic reaction to other drugs like LUPRON, this drug should not be used.

· Report any unusual signs or symptoms to the physician, like continued pubertal changes, substantial mood swings or behavioral changes.


hope this answers your question
thanks