Update on Medical Treatment of Endometriosis: New Drugs or New Therapeutic Approaches?

IF 2 4区 医学 Q2 OBSTETRICS & GYNECOLOGY
Paolo Vercellini, Camilla Buffo, Paola Viganò, Edgardo Somigliana
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引用次数: 0

Abstract

Background: No conceptually new drugs for the safe and successful cure of endometriosis are likely to become available soon. Hormonal modulation of ovarian function and suppression of menstruation remain the pillars of disease control. However, existing drugs may be used following novel modalities to limit the consequences of endometriosis progression.

Objectives: The aims of this review were to propose a pharmacological approach aimed at limiting the potential detrimental effects of the recent dramatic increase in postmenarcheal repetitive ovulatory menses and to define the type of hormones and the routes of administration that can be used to maximize safety and tolerability in the medical treatment of endometriosis.

Methods: For this narrative review, we selected the best quality evidence, prioritizing RCTs, systematic reviews, meta-analyses, network meta-analyses, and international guidelines, preferably published in the last decade.

Outcome: Medical treatment of endometriosis should be included into all aspects of prevention. Very-low-dose combined oral contraceptives can be used for years to counteract the increased risk of ovarian cancer observed in patients with endometriosis. This primary prevention measure saves lives and can effectively integrate targeted risk-reducing surgery. Secondary pharmacological prevention, based on a working diagnosis of early onset adenomyosis-endometriosis selectively in adolescents with severe dysmenorrhea and heavy menstrual bleeding, can potentially impede the development of advanced disease forms, and reduce the need for management of complications due to a delay in diagnosis and treatment. Tertiary prevention, i.e., medical therapy of established disease, is based initially on the safest available estrogen-progestogen combinations and progestogen monotherapies. Whenever possible, ethinyl estradiol and cyproterone acetate should be avoided because of thromboembolic and meningioma risks, respectively. Estradiol can be administered transdermally. Switching to gonadotropin-releasing hormone agonists and antagonists should not be delayed when the first-line agents fail.

Conclusions and outlook: Two-thirds of symptomatic endometriosis patients can be managed satisfactorily for many years using, with the right modality, the existing safe, effective, and well-tolerated medications. Despite the constant plea for new drugs, this already appears to be an excellent clinical outcome, unsurpassed when managing other human chronic inflammatory diseases. Cohort studies are needed to verify whether turning off the recurrent inflammation caused by repeated ovulation and menstruation could also affect the risk of systemic conditions associated with endometriosis.

子宫内膜异位症的医学治疗进展:新药还是新的治疗方法?
背景:目前还没有安全成功治疗子宫内膜异位症的概念性新药。卵巢功能的激素调节和月经的抑制仍然是疾病控制的支柱。然而,现有的药物可以在新的模式下使用,以限制子宫内膜异位症进展的后果。目的:提出一种药理学方法,旨在限制最近月经初潮后重复排卵月经急剧增加的潜在有害影响,并确定可用于子宫内膜异位症医学治疗的激素类型和给药途径,以最大限度地提高安全性和耐受性。方法:在这篇叙述性综述中,我们选择了质量最好的证据,优先考虑随机对照试验、系统综述、荟萃分析、网络荟萃分析和国际指南,最好是在最近十年发表的。结果:子宫内膜异位症的医学治疗应纳入预防的各个方面。非常低剂量的联合口服避孕药可以使用多年来抵消子宫内膜异位症患者患卵巢癌的风险增加。这种初级预防措施可以挽救生命,并可以有效地结合有针对性的降低风险的手术。二级药物预防,基于对有严重痛经和大量月经出血的青少年早发性子宫内膜异位症的有效诊断,可以潜在地阻止晚期疾病形式的发展,并减少因诊断和治疗延误而导致的并发症管理的需要。三级预防,即对既定疾病的药物治疗,最初以最安全的现有雌激素-孕激素联合疗法和孕激素单一疗法为基础。在可能的情况下,应避免使用炔雌醇和醋酸环丙孕酮,因为它们分别有血栓栓塞和脑膜瘤的风险。雌二醇可经皮给药。当一线药物失效时,不应延迟改用GnRH激动剂和拮抗剂。结论与展望:三分之二的症状性子宫内膜异位症患者可以通过正确的方式、现有的安全、有效、耐受性良好的药物治疗多年。尽管对新药的不断请求,这似乎已经是一个很好的临床结果,在管理其他人类慢性炎症性疾病无与伦比。需要进行队列研究来验证关闭由反复排卵和月经引起的复发性炎症是否也会影响与子宫内膜异位症相关的全身疾病的风险。
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来源期刊
CiteScore
4.20
自引率
4.80%
发文量
44
审稿时长
6-12 weeks
期刊介绍: This journal covers the most active and promising areas of current research in gynecology and obstetrics. Invited, well-referenced reviews by noted experts keep readers in touch with the general framework and direction of international study. Original papers report selected experimental and clinical investigations in all fields related to gynecology, obstetrics and reproduction. Short communications are published to allow immediate discussion of new data. The international and interdisciplinary character of this periodical provides an avenue to less accessible sources and to worldwide research for investigators and practitioners.
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