Oral and depot progestin therapy for endometriosis: towards a personalized medicine

ABSTRACT

Introduction: Endometriosis is an estrogen-dependent chronic inflammatory disorder that requires a life-long management plan. Long-term adherence to treatment is pivotal to ensure an effective clinical management. In this optic, one of the cornerstone of endometriosis medical treatment is represented by progestins.

Areas covered: This narrative review examines the clinical efficacy, safety and tolerability of oral and depot progestins used in the treatment of endometriosis. The material included in the current manuscript was obtained with a MEDLINE search through PubMed from inception until February 2017.

Expert opinion: Progestins are effective in controlling pain symptoms in the majority of women with endometriosis, and their effect seems not inferior to that achieved with other compounds used to treat the disease, such as gonadotropin-releasing hormone agonist. Available progestins include a broad range of both oral and depot compounds, and represent, in most cases, an inexpensive treatment option. In addition, progestins do not increase significantly thrombotic risk and could be adopted in those women with metabolic or cardiovascular contraindication to estrogen-progestins. The choice between the different available compounds should be tailored for every woman with preference to the most cost-effective treatment, depending on the most complained symptom and disease location.

KEYWORDS:

• Desogestrel
• dienogest
• endometriosis
• levonorgestrel-intrauterine device
• medroxyprogesterone acetate
• medical therapy
• norethisterone acetate
• progestin

Article highlights

• Endometriosis is an estrogen-dependent chronic inflammatory disorder of fertile age that requires a chronic treatment. Long-term adherence to treatment is pivotal to ensure an effective clinical management.

• Progestins act through the inhibition of inflammatory pathways and responses, provoking apoptosis in endometriotic cells. Moreover, this class of drug stimulate atrophy or regression of endometrial lesions, induce anovulation, inhibit angiogenesis, and decrease expression of matrix metalloproteinases, thus diminishing the invasiveness of endometriotic implants.

• Available progestins adopted in the management of endometriosis include a wide range of both oral and depot compounds, and represent, in most cases, an inexpensive treatment option.

• As there are not enough robust data demonstrating the superiority of one progestin over the others, the first choice should be low-dose oral norethisterone acetate, given the extremely favorable cost-effectiveness profile.

• Future researches on progestins in the treatment of endometriosis should focus on comparison trials with others progestins or estrogen-progestins, and should be designed as superiority trials.

This box summarizes key points contained in the article.

Declaration of interest

E Somigliana reports grants from Ferring and Serono, outside the submitted work. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Additional information

Funding

This paper was not funded.