This protocol is for patients with endometriosis who have a contraindication to, or cannot tolerate, estrogen-containing (combined hormonal) contraceptives. Because combined hormonal options are excluded, progestin-only methods form the appropriate first line of pain management in this population.
The prior step — a first-line progestin-only method (oral, intramuscular, implant, or intrauterine) — targets relief of pelvic pain and dysmenorrhea. When that goal is not achieved with adequate progestin-only treatment, escalation to a structured second-line regimen is warranted. This protocol represents that next step.
Improvement of dysmenorrhea and nonmenstrual pelvic pain.
Progestin-only methods (i.e., oral, depot, implant, or hormonal intrauterine systems) are other first-line options that may be considered for those who cannot tolerate or have contraindications to estrogen.
Second-line treatment options include gonadotropin-releasing hormone (GnRH) receptor agonists with add-back therapy, GnRH receptor antagonists, and danazol.
Use of GnRH receptor agonists should not exceed six months because of these potential adverse effects.
Add-back therapy using high-dose progestin alone (norethindrone acetate, 5 mg orally per day) or low-dose combined estrogen and progestin can mitigate adverse effects and allow for extended treatment courses up to one year.
Oral elagolix (Orilissa) is the first U.S. Food and Drug Administration–approved GnRH antagonist for treating endometriosis.
Once-daily oral relugolix combination therapy containing estradiol and progestin (Myfembree) has also been approved for treatment of moderate to severe endometriosis-associated pain.
Danazol is an androgenic agent that increases free testosterone levels and inhibits pituitary gonadotropin secretion and ovarian enzymes, reducing estrogen production.
They improve dysmenorrhea and nonmenstrual pelvic pain and allow for titration to balance effectiveness and tolerability.
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