From the Guidelines
The recommended treatment for several small left ovarian endometriomas without evidence of other endometriosis foci is medical therapy with progestins, danazol, oral contraceptives, nonsteroidal anti-inflammatory drugs, or gonadotropin-releasing hormone (GnRH) agonists to reduce the size of lesions and manage pain. According to the American College of Obstetricians and Gynecologists (ACOG) committee 1, current evidence suggests that these medical therapies can reduce the size of lesions and manage pain caused by endometriosis.
Key Considerations
- Medical therapy has not been proven to eradicate lesions, but it can help manage symptoms and reduce lesion size 1.
- Surgery may be considered for women with persistent pain despite medical therapy, rapid growth, or when malignancy cannot be excluded 1.
- GnRH agonists, such as leuprolide, may be used for refractory cases, but their use should be limited to 6-12 months due to concerns about bone density loss 1.
- Add-back therapy, such as norethindrone acetate or conjugated estrogen with medroxyprogesterone, may be used to reduce GnRH-induced bone mineral loss without reducing the efficacy of pain relief 1.
Treatment Options
- Progestins, such as norethindrone acetate (5-15 mg daily), medroxyprogesterone acetate (30-100 mg daily), or a levonorgestrel intrauterine device, can be effective in managing symptoms and reducing lesion size.
- Oral contraceptives, such as combined hormonal contraceptives (CHCs), can be used to suppress menstruation and reduce estrogen levels, which can help inhibit the growth of endometrial tissue.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to manage pain symptoms associated with endometriosis.
Monitoring and Follow-up
- Regular monitoring with pelvic ultrasound every 6-12 months is recommended to assess treatment response and endometrioma size changes.
- Women with endometriomas should be followed up regularly to monitor for any changes in symptoms or lesion size, and to adjust treatment as needed.
From the FDA Drug Label
Initial daily dosage of 5 mg norethindrone acetate tablets for two weeks. Dosage should be increased by 2. 5 mg per day every two weeks until 15 mg per day of norethindrone acetate tablets is reached. Norethindrone Acetate Tablets, USP are indicated for the treatment of ... endometriosis
The recommended treatment for several small left ovarian endometriomas without evidence of other endometriosis foci is norethindrone acetate. The initial daily dosage is 5 mg for two weeks, increasing by 2.5 mg every two weeks until 15 mg per day is reached. Therapy may be held at this level for six to nine months or until annoying breakthrough bleeding demands temporary termination 2. Norethindrone acetate is indicated for the treatment of endometriosis 2.
From the Research
Treatment Options for Ovarian Endometriomas
- The recommended treatment for several small left ovarian endometriomas without evidence of other endometriosis foci is laparoscopic surgery, specifically ovarian cystectomy 3.
- Ovarian cystectomy is preferred over cyst ablation or sclerotherapy as it enables pathologic diagnosis, improves symptoms, prevents recurrence, and optimizes fertility outcomes 3, 4, 5.
- Preoperative and postoperative hormonal suppression can improve operative outcomes and decrease the risk of endometrioma recurrence 3.
- Medical management, such as combined oral contraceptives and progestins, can also be effective in alleviating pain symptoms and may be considered as a first-line treatment 6, 5.
Considerations for Surgical Management
- Surgical management of endometriomas should be individualized, taking into account the patient's ovarian reserve status and reproductive plans 4, 5.
- Careful ovarian cyst excision with the goal of preserving ovarian tissue and treating additional endometriosis is crucial for optimal outcomes 5.
- The choice of surgical technique, such as bipolar hemostasis, should be carefully considered to minimize damage to ovarian reserve 4.
Expectant Management
- Expectant management may be considered for asymptomatic patients with small, stable endometriomas, as it may not harm fertility outcomes and can avoid surgical risks 5.