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  CHAPTER  9       4          E     n    d      o   m    e    t    r   i      o    s   i      s      94  END O ME TRI O SIS   Persistent Pelvic Pain . . . . . . . . . . . . . . . . . . . . Level II   Connie Kraus, PharmD, BCPS   LEARNING OBJECTIVES   After completing this case study ,  the reader should be able to: Identify the signs and symptoms associated with endometrio- sis.  Compare and contrast the benefits and risks associated with various hormonal medications used for treatment of endo- metriosis-associated pelvic pain. Determine a treatment approach for this case taking into account other health issues and potential health  benefi ts.  Discuss possible side effects associated with treatment for endometriosis.  PATIENT PRESENTATION   Chief Complaint   “Although  the pain associated with my menstrual period is better, the naproxen upsets my stomach, and I am still having pain in my lower abdomen at other times during the month.”   HPI  Lisbeth Anderson is a 30-year-old woman who was diagnosed with endometriosis 3 months ago based on a history of dysmenorrhea, intermittent pain with defecation, and past history of dyspareunia. She presents to the nurse practitioner today for evaluation and management of continued endometriosis-related pain despite treat- ment with naproxen.  PMH  s/p deep vein thrombosis 4 years ago after a flight to Southeast Asia; treated for 6 months with warfarin; no r  e cur  r  e nc e   G1P1A0; one healthy male child aged 2 years  FH  Mother (aged 57 years) has a history of endometriosis, no other health conditions; father (aged 58 years) has hypertension and elevated cholesterol; one female sibling (aged 25 years) is healthy.  SH  Patient is a freelance  photographer. She has one child. She is single; not currently sexually active. She does not smoke and consumes no more than two alcohol-containing  beverages  per week. She exercises 30 minutes most days of the week.  Meds   Naproxen 250 mg three times daily with food at first sign of menses for 5  –  7 days was begun at previous visit. Multivitamin one daily.  All   NKDA  ROS  (+) For moderate pain in pelvic region, (−)  for constipation, men- strual periods occur at regular intervals of 29 days  Physical Examination   Gen  WDWN female in NAD  VS   BP 115/70, P 65, RR 15, T 37°C; Wt 72 kg, Ht 5′11″;  patient has maintained same weight pre-pregnancy and postpregnancy  Skin   No lesions   HEENT   WNL   Neck/Lymph  Nodes  Supple, no bruits, no adenopathy, no thyromegaly   L ung   s/  Thor  ax  CTA bilaterally   Br  easts  Supple; no masses  CV    RRR, normal S and S  247 1 2  SECTION   9          W omen’s Health  (Gynecologic D     i      s    o   r    d      e   r    s     )      248    Abd   Soft; patient states at baseline she experiences pain that averages a “4”  on a 0  –  10 pain scale (with 10 being the worst  possible  pain), (+) BS; no masses noted   Genit/Rect    Pelvic exam: (+) adnexal pain elicited and rated at “6”  on a 10-point scale, no masses   MS/Ext   Pulses intact   Neur  o   Normal sensory and motor levels  Labs    Na 135 mEq/L  Fasting lipid profi le K 3.8 mEq/L T. chol 140 mg/dL Cl 104 mEq/L LDL 55 mg/dL CO 2 25 mEq/L HDL 65 mg/dL BUN 10 mg/dL Trig 100 mg/dL SCr 0.6 mg/dL Random Glu 89 mg/dL  Other   PAP smear: No r  mal Chlamydia/gonorrhea: Negative Urine pregnancy test: Negative  A ssessment  A 30-year-old woman with recent diagnosis of endometriosis with chronic pelvic pain; partial relief from dysmenorrhea with naproxen. Because of naproxen-related side effects and pain at other times  besides during menses, would like to consider hormonal treatment options.  QUESTIONS  Problem Identifi cation   1.a. What are the patient ’ s  current medication-related problems? 1.b. What information indicates the severity of this patient ’ s  problems?  Desired Outcome   2. What are the goals of therapy for this  patient’s  endometriosis  pain?  T herapeutic   Alternatives   3.a. What nondrug therapies might be useful for this patient? 3.b. What hormonal options are available for the treatment of endometriosis? 3.c. What are the potential risks and benefits of the various tr  eat- ment options for this patient? 3.d. Are there any treatments contraindicated in this patient?  Optimal Plan   4. What drug, dosage form, dose, schedule, and duration are best for this patient?  Outcome Evaluation   5. What clinical and laboratory parameters are necessary to evalu- ate the therapy for achievement of the desired therapeutic out- come and to detect or prevent adverse effects?  Patient Education   6. What information should be provided to the patient to enhance adherence to the medication, ensure successful therapy, and minimize adverse effects?  CLINICAL C O URS E   The patient returns to her nurse practitioner 6 months after start- ing medroxyprogesterone acetate 150 mg intramuscular injections every 3 months. She reports that her  pelvic  pain is better controlled with an overall average rating pain of “1”  on the 10-point scale. She states that she had intermittent spotting initially, but now has no menstrual periods.  Follow-Up Questions   1. What is the optimal length of time for a patient to continue on medroxyprogesterone acetate injections for treatment of endometriosis-related chronic  pelvic  pain? 2. Are there other options that this patient could select to achieve similar results with the same or better side-effect  profile? 3. Would your recommendation change if this patient had risk fac- tors for osteopenia or future osteoporosis? 4. Would your recommendation change if this patient had indi- cated an interest in having another child in the next 1  –  2 years?  SELF-STUDY ASSIGN M ENTS   1. Research complementary therapies that have been studied for the relief of endometriosis, and compare the evidence for their efficacy with standard treatments. 2. Review the contraindications of the various contraceptive agents used for treatment of endometriosis.  CLINICAL PEARL   Pharmacologic treatment of endometriosis may be useful for decreasing pain. Pharmacotherapeutic agents that mimic preg- nancy or menopause are the cornerstone of treatment. All of these agents have similar efficacy in treating pain, but have different side-effect profiles. Treatment with hormonal therapy does not improve fertility, which can also be a potential consequence of the disease.  REFERENCES   1. Wieser F, Cohen M, Gaeddert A, et al. Evolution of medical tr  eat- ment for endometriosis: back to the roots? Hum Reprod U  pdat e   2007;13(5):487  –  499.  2. Flower A, Liu JP, Chen S, Lewith G, Little P. Chinese herbal medicine for endometriosis. Cochrane Database Syst Rev 2009;(8):CD006568. 3. The Practice Committee of the American Society for Reproductive Medicine. Treatment of pelvic pain associated with endomet r  iosis. Fertil Steril 2006;86(Suppl 4):S18  –  S27. 4. Ozkan S, Arici A. Advances in treatment options of endomet r  iosis.  Gynecol Obstet Invest 2009:67:81  –  91. 5. Garquhar C. Endometriosis. BMJ 2007;334:249  –  253.    6. Petta CA, Ferianni RA, Abrao MS, et al. Randomized clinical tr  ial of a levonorgestrel-releasing intrauterine system and a depot G nRH analogue for the treatment of chronic  pelvic  pain in women with endo- metriosis. Hum Reprod 2005;7:1993  –  1998. 7. Walch K, Unfried G, Huber J, et al. Implanon ® versus medr  o xy  p r  o- gesterone acetate: effects on pain scores in patients with sy mpt omatic endometriosis  —  a pilot study. Contraception 2009;70:29  –  34. 8. Selak V, Farquhar C, Prentice A, Singla A. Danazol for pelvic pain associated with endometriosis. Cochrane Database Syst Rev  2007;(4):CD000068.  9. Davis L, Kennedy SS, Moore J, Prentice A. Modern combined oral c o n- traceptives for pain associated with endometriosis. Cochrane Database Syst Rev 2007;(3):CD001019. 10. Hatcher RA, Trussell J, Nelson AL, Cates W Jr, Stewart FH, Kowal D. Contraceptive Technology, 19th ed. Contraceptive Technology Communications Inc, 2007. 11. Department of Reproductive Health, World Health Organization. Medical eligibility criteria for contraceptive use. Available at:  htt   p://www.w ho .int/r  e  p ro duct  ivehealth/publicat  ions/family_plan ning/9789241563888/en/index.html  . Accessed May 9, 2010. 


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