QUESTION 11
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Q2(h). Medical management of endometriosis. (10 Marks)
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Clinical Response
Short Answer Q2(h) — 10 MARKS
Medical Management of Endometriosis
| Agent Class | Details |
|---|---|
| NSAIDs | First-line symptomatic analgesia for dysmenorrhoea; does not treat underlying disease progression |
| Combined oral contraceptives | First-line hormonal therapy — continuous or cyclical use suppresses ovulation and reduces menstrual flow, providing symptomatic relief with a favourable long-term safety profile |
| Progestins (oral, depot, or LNG-IUS) | Effective alternative/adjunct — induce endometrial decidualisation and atrophy of ectopic implants; LNG-IUS particularly useful for associated heavy menstrual bleeding |
| GnRH agonists (e.g., leuprolide) | Induce a hypoestrogenic “medical menopause” state, effective for pain control; use limited by hypoestrogenic side effects (bone density loss, vasomotor symptoms) unless combined with “add-back” hormone therapy |
| GnRH antagonists (e.g., elagolix, relugolix combinations) | Newer oral agents providing more rapid, dose-dependent oestrogen suppression without the initial flare effect of agonists; increasingly used with built-in low-dose hormonal add-back to balance efficacy and bone/vasomotor side effects |
| Aromatase inhibitors | Adjunctive option in refractory cases, particularly where extra-ovarian oestrogen production (from ectopic implants themselves) contributes to persistent symptoms despite ovarian suppression |
Clinical Pearl
Medical therapy for endometriosis treats symptoms (primarily pain) by suppressing the hormonal drive to ectopic implants — it does not eliminate existing lesions or adhesions, so symptoms typically recur once therapy is stopped, and medical therapy does not reliably improve fertility (surgery remains the mainstay for endometriosis-associated infertility).
Consolidated References
- Nicolaides KH. Screening for fetal aneuploidies at 11 to 13 weeks. Prenat Diagn. 2011.
- Wald NJ, et al. Antenatal maternal serum screening for Down’s syndrome — quadruple test performance data. J Med Screen.
- Rolnik DL, et al. Aspirin versus placebo in pregnancies at high risk for preterm pre-eclampsia (ASPRE trial). N Engl J Med. 2017.
- FIGO Working Group on Good Clinical Practice in Maternal-Fetal Medicine. Best practice for first-trimester risk assessment and pre-eclampsia prevention.
- Assisted Reproductive Technology (Regulation) Act, 2021, and Rules, Government of India.
- ACR-SPR / ACOG practice guidance on MRI use in pregnancy.
- Practice Committee of the American Society for Reproductive Medicine. Mature oocyte cryopreservation — a guideline. Fertil Steril.
- ERAS Society. Enhanced Recovery After Surgery guidelines for gynaecologic/oncologic surgery and caesarean delivery.
- Ministry of Health and Family Welfare, Government of India. Surakshit Matritva Aashwasan (SUMAN) guidelines.
- Harlow SD, et al. Executive summary of the Stages of Reproductive Aging Workshop + 10 (STRAW+10). Menopause. 2012.
- Advincula AP, et al. Role of robotic surgery in benign and oncologic gynaecology — review. Obstet Gynecol Clin North Am.
- Johnson NP, et al. ESHRE Guideline: management of women with endometriosis (medical therapy section). Hum Reprod.
Model Answer Key — Obstetrics & Gynaecology Paper IV, MPMSU Jabalpur (June 2023) | For academic study purposes