Weighing up GnRH agonist therapy for endometriosis: outcomes and the treatment paradigm

Endometriosis is a chronic inflammatory estrogen-dependent disease affecting 10% of women worldwide leading to chronic pelvic pain and infertility which may be treated clinically or surgically. Current literaure was reviewed using the keywords 'gonadotropin releasing hormone agonists (GnRHa),' 'endometriosis,' 'infertility' and 'chronic pelvic pain.' Relevant papers prioritizing randomized controlled clinical trials (RCT), systematic reviews, meta-analyses, as well as international guidelines were evaluated. Available options for relieving endometriosis associated pain include GnRHa, progestagens and combined oral contraceptives all of which block menstruation to control symptoms without curing the disease. GnRHa administration decreases pain and symptom recurrency after surgical treatment but side effects and costs limit its use. Published studies to test its effectiveness in easing endometriosis associated pain are heterogeneous, consider different outcomes with no long term results. Drug choice should be individualized considering the side-effects profile, tolerability, costs, risks and benefits as one size does not fit all. As we wait for the development of an ideal pharmacological agente, GnRHa with an add-back regimen remain a second line option to alleviate the painful symptoms in women with endometriosis. Endometriosis management should consider the systemic nature of the disease and the complexity involved in the pathogenesis of symptoms.