Endometriosis cannot be predicted by hormonal effects

Endometriosis not predicted by hormone effect
Internal Medicine News, Feb 1, 2008 by Miriam E. Tucker

WASHINGTON — Response to hormonal therapy does not accurately predict whether a patient has endometriosis, Dr. Todd R. Jenkins reported at the annual meeting of the AAGL.

Laparoscopy has long been considered the standard for diagnosing endometriosis. However, a 1999 paper by Dr. Frank W. Ling called into question the necessity for doing laparoscopy in women with chronic pelvic pain (Obstet. Gynecol. 1999;93:51-8). The findings of that study, which was sponsored in part by depot leuprolide manufacturer TAP Holdings Inc., suggested instead that a diagnostic algorithm plus a reduction in symptoms with a 3-month trial of depot leuprolide could non-invasively identify those women for whom endometriosis was the cause of pain.

“Our clinical impression has been that many women who failed to respond to hormonal treatment did, in fact, have endometriosis. Unfortunately, many women have been told that they did not have endometriosis since they did not respond to hormonal treatment,” said Dr. Jenkins, director of the division of women’s reproductive health care in the department of obstetrics and gynecology at the University of Alabama at Birmingham.

In a retrospective study conducted by Dr. Jenkins and his then-associates at the Chattanooga (Tenn.) Women’s Laser Center, chart reviews identified 486 patients at the private endometriosis referral center who had undergone laparoscopy for chronic pelvic pain and who had received at least 3 months of preoperative hormonal therapy. Of those, a total of 105 met the study criteria, which included complete information regarding response to treatment and less than 3 months between completion of hormonal therapy and the laparoscopy.

The hormonal treatments were oral contraceptive pills in 80% of the patients and gonadotropin-releasing hormone (GnRH) agonists in 20%. Response to the hormones, defined as either partial or complete symptom relief, was achieved in 46% (48), while 54% (57) had no relief of symptoms. Endometriosis was identified subjectively during laparoscopy in 84% (88) of the women, and a pathological diagnosis was made in 67% (70). These findings confirm those of Dr. Ling and others that endometriosis is present in approximately 80%-85% of women with well-defined chronic pelvic pain, Dr. Jenkins noted.

There was no significant difference in the rate of endometriosis between all hormonal therapy responders and nonresponders, either by subjective impression or pathological diagnosis. Subjective diagnoses of endometriosis were made for 85% of responders (41/48) and 81% of nonresponders (46/57), and pathological diagnoses in 65% (31/48) and 68% (39/57), respectively. Endometriosis rates also did not differ between the 35 responders and 48 nonresponders to oral contraceptives specifically.

Differences were significant for those who took GnRH agonists: Subjective diagnoses of endometriosis were made in 100% (9/9) of responders, compared with just 50% (4/8) of nonresponders, and pathological diagnoses in 89% (8/9) of responders vs. 25% (2/8) of nonresponders. However, the number of cases was too small to be conclusive, he said.

Response to hormonal therapy also did not predict the diagnosis of endometriosis at any specific location except for the anterior bladder wall peritoneum (70% of responders vs. 30% of nonresponders), but only 10 patients had endometriosis at that site. The same was found for pathologically confirmed diagnoses: Only endometriosis of the anterior peritoneum was statistically more likely among responders than nonresponders (85% vs. 15%), and again, the data were limited because the numbers were very small, Dr. Jenkins added.

He noted that these findings should not be interpreted to mean that a trial of GnRH agonists isn’t a good idea, since they were found to be the most effective hormonal treatment for the relief of symptoms. “We do not disagree with a trial of empiric therapy in patients with chronic pelvic pain. But no judgment should be made regarding the diagnosis of endometriosis based on the response to hormonal therapy without a laparoscopic evaluation. A laparoscopic diagnosis is still the gold standard.”

BY MIRIAM E. TUCKER

Senior Writer
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