When I am asked about my use ofsuppressive medications such as Lupron and Synarel, I think it is most important to understand the actual effect of these agents. Synarel and Lupron (and Zoladex and RU-486) are excellent tools for creating a drug-induced ovarian failure. These drugs work on the pituitary gland to deplete it of all gonadotropins. When that happens, ovarian function stops. That, in turn, can result in stabilization of areas of endometriosis which had been active and causing pain. Studies demonstrate that, when used appropriately, some women do not have clinical progression of their disease while they take the drug. Along with this stabilization, many women report an improvement in their pain. However...
It is equally important to understand what these drugs cannot do. There is NO evidence that women treated with these agents have their endometriosis cured. On the contrary, there is ample evidence that most women have a prompt return of symptoms after they discontinue the drug. Menopause is a clinical situation which can be quite similar to the state induced by Lupron or Synarel treatment. When you consider that women who still have implants of endometriosis in their pelvis after menopause are very likely to have problems when postmenopausal hormone therapy is begun, it is hard to understand why anyone would reasonably expect a long-term cure from creating a state of extreme hypoestrogenism (lack of estrogen). In truth, if the implants are present, they can respond to stimulation. There has never been a medication that will cure the disease.
Suppressive therapies, as I believe these medications should be called, are limited in usefulness by the length of time they can be safely taken (usually six-twelve months), their high cost, and commonly incapacitating side effects. In my personal experience here at my Center, only about one out of three women have completed a full six-twelve months of treatment.
I *have* used these medications very sparingly over the years, in the following situations:
If a patient is planning surgical excision of her disease and she has *extremely* large masses or widespread disease, it may help to reduce the size of her lesions and make the surgical procedure a more efficient one. Usually, however, I prefer that she not be on these drugs, so that any subtle disease is not further suppressed. The point of the surgery is to remove all disease, so I need to see it if it is present.
If we see a patient who was operated on by another physician and we know from the operative report or the video that disease was left behind, these drugs (providing the patient can tolerate them) can buy the patient some time before she has to consider another surgery. This is, of course, her choice base on full understanding and education about the drug(s).
Finally, these drugs can be used with a patient who for any reason is not a candidate for excision of her disease. Remember, however, her disease will remain present a temporarily suppressed state and symptoms will undoubtedly recur at cessation of therapy.
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