Thursday, March 18, 2010

Depot Provera in endometriosis

Medical Treatment for endometriosis can be tried in unmarried girls, those who have finished family, and in whom pain is the troublesome symptom. Two strategies for medical treatment are:

  • pseudo-menopausal regime

  • pseudo-pregnancy regime

Pseudo- menopausal state is achieved using GnRH analogues, and pseudo-pregnancy regime by progestrone. both alters the hormonay mileu, suppresses HPO axis (there by reduces the growth of ectopic endometrium), alters peritoneal immune system (controlled by hormones and is associated with the development of endometriosis).

Pseudomenopausal regime is associated with menopausal symptoms, osteoporosis, and GnRHa s are costly. pseudo-pregnancy regime can be administered much more easily, using Depot Provera (Medroxy Progestrone Acetate). It's given once in 3 months injection (more frequent injections as adviced in certain texts are not required). It maintains a constant level of progestrone in the body, suppresses HPO, and keeps endometrium thin. We expect the ectopic endometrium also to be maintained thin, and together with altered immune function, endometrium is expected to heal.

Unpredictable irregular bleeding is the side effect with Depot Provera. As endometrium is thin, estrogen can be administered, which heals the endometrium. (Ethnyl Estradiol 10mcg TDS during bleeding days). Patient is adviced to take estrogen during bleeding days. Initially during therapy bleeding is more frequent. It's usually minimal or scanty, not painful. gradually, bleeding becomes quite infrequent, even amenorrhea will occur. There's no fear of permanant amenorrhea, as the state is purely hormonal, and any time, on treatment with estrogen-progestrone, normal cycles can be brought about.

I have treated many cases of endometriosis with this regime. Symptomatic relief is great, and ultrsonically regression of endometriosis can be proven. There's little side effects or discontinuation of treatment. Patients are so happy that, they refuse to stop the drug.

Here's one of the patients, who was P2L2, had troublesome secondary dysmenorrhea (Secondary dysmenorrhea to be distinguished from Primary Dysmenorrhea, which is sever on the first day, and is alleviated as the bleeding increases on the second day. Secondary dysmenorrhea becomes more severe as bleeding increases on second and third day.) She was given Depot Provera 2 years back. She took 2 injections (6 months) and as the symptoms reduced, she stopped the drug, and was having normal cycles. She came back again recently, as her symptoms have reappeared. I sent her for scan expecting to see the lesions increased. To my surprise, the lesions had reduced drastically (even with no treatment for 2 years). This not only proves the effect of Depot Provera, but also that endometriosis can spontaneously regress.

2 years back:




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