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{{Endometriosis}}
{{Endometriosis}}


{{CMG}}; {{AE}} {{AKI}}
{{CMG}}; {{AE}} {{S.G.}}, {{AKI}}


==Overview==
==Overview==
The mainstay of therapy for endometriosis is [[pain]] management and regression of [[Endometrium|endometrial lesions]]. [[NSAIDS|NSAIDs]] are useful for [[pain]] management. There are many therapeutic options available to reduce the size of endometrial [[lesions]]. [[Gonadotropin-releasing hormone agonist|Gonadotrophin releasing hormone agonists]] and [[danazol]] are widely used. Continuous [[Combined oral contraceptive pill|oral contraceptive pill]] use is also helpful in [[Patient|patients]] with mild to [[Moderate chronic pain|moderate]] [[endometriosis]].
==Medical Therapy==
==Medical Therapy==
Currently, there is no cure for endometriosis, though in some patients menopause (natural or surgical) will abate the process. Nevertheless, a hysterectomy and/or removal of the ovaries will not guarantee that the endometriosis areas and/or the symptoms of endometriosis will not come back. Conservative treatments usually try to address pain or infertility issues. Medical herbal treatments can sometimes be effective in controlling the disease.
The treatment of [[endometriosis]] is a combination of [[medical]] and surgical therapy based on the extent of the disease, the age of the patient, and the desire of the patient to [[Conceive a child|conceive]]. The primary goal of [[medical]] [[therapy]] is the [[symptomatic]] improvement of pain and regression of the [[Endometrium|endometrial]] [[lesions]].<ref name="pmid28139238">{{cite journal| author=Bedaiwy MA, Alfaraj S, Yong P, Casper R| title=New developments in the medical treatment of endometriosis. | journal=Fertil Steril | year= 2017 | volume= 107 | issue= 3 | pages= 555-565 | pmid=28139238 | doi=10.1016/j.fertnstert.2016.12.025 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28139238  }} </ref><ref name="pmid27615386">{{cite journal| author=Benagiano G, Guo SW, Bianchi P, Puttemans P, Gordts S, Petraglia F et al.| title=Pharmacologic treatment of the ovarian endometrioma. | journal=Expert Opin Pharmacother | year= 2016 | volume= 17 | issue= 15 | pages= 2019-31 | pmid=27615386 | doi=10.1080/14656566.2016.1229305 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27615386 }} </ref><ref name="pmid23356536">{{cite journal| author=Streuli I, de Ziegler D, Santulli P, Marcellin L, Borghese B, Batteux F et al.| title=An update on the pharmacological management of endometriosis. | journal=Expert Opin Pharmacother | year= 2013 | volume= 14 | issue= 3 | pages= 291-305 | pmid=23356536 | doi=10.1517/14656566.2013.767334 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23356536  }} </ref>
 
*[[Endometriosis]] occurs due to increased levels of [[estrogen]]. This may be a result of excess production in the body or [[exogenous]] [[estrogen]] intake. Therefore, the primary goal of [[medical]] [[therapy]] is to shut off the [[estrogen]] supply which is essential for the growth of the [[Endometrium|endometrial]] [[lesions]].<ref name="pmid23427639">{{cite journal| author=Mateo Sánez HA, Mateo Sánez E, Hernández AL, Salazar Ricarte EL| title=[Treatment of patients with endometriosis and infertility]. | journal=Ginecol Obstet Mex | year= 2012 | volume= 80 | issue= 11 | pages= 705-11 | pmid=23427639 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23427639 }} </ref>
The treatments for endometriosis pain include:
*[[Treatment Planning|Treatment]] of [[Patient|patients]] with mild to [[Moderate chronic pain|moderate]] [[pain]] ([[pain]] is not couse of absence) is [[Non-steroidal anti-inflammatory drug|nonsteroidal anti-inflammatory drugs]] ([[NSAIDs]]).<ref name="BrownCrawford2017">{{cite journal|last1=Brown|first1=Julie|last2=Crawford|first2=Tineke J|last3=Allen|first3=Claire|last4=Hopewell|first4=Sally|last5=Prentice|first5=Andrew|title=Nonsteroidal anti-inflammatory drugs for pain in women with endometriosis|journal=Cochrane Database of Systematic Reviews|year=2017|issn=14651858|doi=10.1002/14651858.CD004753.pub4}}</ref>
 
**[[COX-2 inhibitor|COX-2 inhibitors]] ([[celecoxib]], [[rofecoxib]], and [[valdecoxib]]) are avoided for [[Patient|patients]] [[desire]] [[pregnancy]].<ref name="Pall2001">{{cite journal|last1=Pall|first1=M.|title=Induction of delayed follicular rupture in the human by the selective COX-2 inhibitor rofecoxib: a randomized double-blind study|journal=Human Reproduction|volume=16|issue=7|year=2001|pages=1323–1328|issn=14602350|doi=10.1093/humrep/16.7.1323}}</ref><ref name="DuffyVandeVoort2011">{{cite journal|last1=Duffy|first1=Diane M.|last2=VandeVoort|first2=Catherine A.|title=Maturation and fertilization of nonhuman primate oocytes are compromised by oral administration of a cyclooxygenase-2 inhibitor|journal=Fertility and Sterility|volume=95|issue=4|year=2011|pages=1256–1260|issn=00150282|doi=10.1016/j.fertnstert.2010.12.048}}</ref>
* [[NSAID]]s and other pain medication: They often work quite well as they not only reduce pain but also menstrual flow. They are commonly used in conjunction with other therapy. For more severe cases narcotic prescription drugs may be used.
*
*[[GnRH agonist|Gonadotropin Releasing Hormone (GnRH) Agonist]]: These agents work by increasing the levels of GnRH. Consistent stimulation of the GnRH receptors  results in downregulation.  This causes a decrease in FSH and LH, thereby decreasing estrogen and progesterone levels.
*Among [[Patient|patients]] without [[Medicine|medical]] [[contraindications]], the best [[Treatment centre|treatment]] is [[Combination therapy|combination]] of [[estrogen]]-[[progestin]] [[Birth control|contraceptives]] [[Combination therapy|combined]] and [[Non-steroidal anti-inflammatory drug|NSAID]].<ref name="BedaiwyAllaire2017">{{cite journal|last1=Bedaiwy|first1=Mohamed A.|last2=Allaire|first2=Catherine|last3=Alfaraj|first3=Sukinah|title=Long-term medical management of endometriosis with dienogest and with a gonadotropin-releasing hormone agonist and add-back hormone therapy|journal=Fertility and Sterility|volume=107|issue=3|year=2017|pages=537–548|issn=00150282|doi=10.1016/j.fertnstert.2016.12.024}}</ref>
* It is suggested but unproven that pregnancy and childbirth can stop endometriosis.
**[[Progestin]]-only [[Oral contraceptive|contraceptive pills]] such as [[norethindrone]] 0.35 [[Milligram|mg]] (once daily) [[Combination therapy|combined]] with an [[Non-steroidal anti-inflammatory drug|NSAID]] is used among [[patient]] who can not use [[Hormone replacement therapy|estrogen therapy]].<ref name="AllenVillavicencio2016">{{cite journal|last1=Allen|first1=Rebecca|last2=Villavicencio|first2=Jennifer|title=Unscheduled bleeding and contraceptive choice: increasing satisfaction and continuation rates|journal=Open Access Journal of Contraception|year=2016|pages=43|issn=1179-1527|doi=10.2147/OAJC.S85565}}</ref>
* Hormone suppression therapy: This approach tries to reduce or eliminate menstrual flow and  estrogen support. Typically, it needs to be done for several months or even years.
**[[Intramuscular injection]] of [[medroxyprogesterone acetate]] ([[Medroxyprogesterone acetate (oral)|MPA]]) 150 [[Milligram|mg]] can helpful every three months.<ref name="urlDailyMed - MEDROXYPROGESTERONE ACETATE- medroxyprogesterone acetate injection, suspension">{{cite web |url=https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=428481bb-b7cf-4d76-b57d-0d6bfa2b6ac3 |title=DailyMed - MEDROXYPROGESTERONE ACETATE- medroxyprogesterone acetate injection, suspension |format= |work= |accessdate=}}</ref>
** [[Progesterone]] or [[Progestins]]: Progesterone counteracts estrogen and inhibits the growth of the endometrium. Such therapy can reduce or eliminate menstruation in a controlled and reversible fashion.  Progestins are chemical variants of natural progesterone.
**[[Subcutaneous injection]] of [[medroxyprogesterone acetate]] ([[Medroxyprogesterone acetate (oral)|MPA]]) 104 [[Milligram|mg]] can helpful every three months.<ref name="urlDailyMed - MEDROXYPROGESTERONE ACETATE- medroxyprogesterone acetate injection, suspension" />
** Avoiding products with [[xenoestrogen]]s, which have a similar effect to naturally produced estrogen and can increase growth of the endometrium.
**[[Norethindrone acetate]] 5 [[Milligram|mg]] can be used by mouth daily (the dose can range from 2.5 mg to 15 mg daily).<ref name="urlDailyMed - AYGESTIN- norethindrone acetate tablet">{{cite web |url=https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=69f5bc4b-758d-471b-ad8d-17c94f8e0963 |title=DailyMed - AYGESTIN- norethindrone acetate tablet |format= |work= |accessdate=}}</ref>
** Continuous [[hormonal contraception]] consists of the use of [[combined oral contraceptive pill]]s without the use of placebo pills, or the use of [[NuvaRing]] or the [[contraceptive patch]] without the break week. This eliminates monthly bleeding episodes.
**[[Adverse effect (medicine)|Side effects]] of [[progestin]] [[Therapy|treatment]] is:<ref name="urlMenopause and Hormone Replacement - Endotext - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK279050/ |title=Menopause and Hormone Replacement - Endotext - NCBI Bookshelf |format= |work= |accessdate=}}</ref>
** [[Danazol]] (Danocrine) and [[gestrinone]] are suppressive steroids with some androgenic activity. Both agents inhibit the growth of endometriosis but their use remains limited as they may cause [[hirsutism]]. There has been some research done at Case Western Reserve University on a topical Danocrine, applied locally, which has not produced the hirsutism characteristics. The study has not yet been published in a medical journal.
***Irregular [[uterine]] [[bleeding]]
** Gonadotropin releasing hormone agonists ([[GnRH agonist]]s) induce a profound [[hypoestrogenism]] by decreasing FSH and LH levels. While quite effective, they induce unpleasant menopausal symptoms, and over time may lead to [[osteoporosis]]. To counteract such side effects some estrogen may have to be given back (add-back therapy).
***Spotting
**[[Aromatase inhibitor]]s are medications that block the formation of estrogen and have become of interest for researchers who are treating endometriosis.<ref>Attar E, Buttun SE. Aromatase inhibitors: the next generation of therapeutics for endometriosis? Fertil Steril 2006;85:1307-18 PMID 16647373</ref>
***[[Amenorrhea]]
 
***[[Weight gain]]
* Surgical treatment is usually a good choice if endometriosis is extensive, or very painful. Surgical treatments range from minor to major surgical procedures.
***[[Mood]] changes
** [[Laparoscopy]] is very useful not only to diagnose endometriosis, but to treat it. With the use of scissors, cautery, lasers, hydrodissection, or a sonic scalpel, endometriotic tissue can be ablated or removed in an attempt to restore normal anatomy. Studies have shown that with true excision [http://www.endometriosissurgeon.com] such as the Redwine Method, recurrence rates are less than 20%.
***[[Bone]] loss
** [[Laparotomy]] can be used for more extensive surgery either in attempt to restore normal anatomy, or at least preserve reproductive potential.
***[[Reduction]] in [[High density lipoprotein|high-density lipoprotein]] ([[High density lipoprotein|HDL]]) [[cholesterol]]
**[[Hysterectomy]] (removal of the [[uterus]] and surrounding tissue) and bilateral salpingo-oophorectomy (removal of the [[fallopian tubes]] and [[ovaries]]).
***Increases in [[Low density lipoprotein|low-density lipoprotein]] ([[LDL Cholesterol|LDL]])  [[cholesterol]] and [[Triglyceride|triglycerides]]
**[[Bowel resection]] can be useful if there is bowel involvement.
*
**For patients with extreme pain, a presacral [[neurectomy]] may be indicated where the nerves to the uterus are cut.
*There are several [[therapeutic]] agents available to decrease [[estrogen]] production. The following table is a description of different [[therapeutic]] agents available for the treatment of [[endometriosis]].
 
{| class="wikitable"
* Raising your [[serotonin]] level: low serotonin levels reduce the pain threshold, and make people more vulnerable to every pain. Women particularly need adequate amounts of light during the second half of their menstrual cycles, when their serotonin levels may already be low.
!Drug Class
** Many people like sweets: eating sugar or chocolate temporarily increases serotonin levels, but creates a rebound effect, characterized by heightened PMS symptoms.
!Drugs
** [[Melatonin]] and [[serotonin]] are increased by [[meditation]], and the stress hormone [[cortisol]] is decreased. Melatonin causes you to go into delta-sleep, during which period Human Growth Hormone is released. As melatonin levels drop from childhood (100%) to age 20 (30%) and age 30 (20%), recovering takes more time, so good deep sleep is essential.
!Duration of therapy
** Serotonin is manufactured by the body from a partial protein or amino acid called tryptophan. This amino acid is found in many foods, including soy, turkey, chicken, halibut, and beans.
!Mechanism of Action
** [[Lavender]], primarily in the form of oil, has been found to reduce several physiological parameters of stress by stimulating serotonin and inducing a feeling of calm and happiness.
!Side effects of therapy
** [[Light therapy]] increases your [[serotonin]] levels.
|-
 
| rowspan="4" |[[Gonadotropin-releasing hormone agonist|Gonadotrophin releasing hormone agonists]]
* Complementary or [[Alternative medicine]] are used by many women who get great relief from the pain and discomforts from a variety of available treatments.
|[[Leuprolide|Leuprolide acetate]]
** [[Nutrition]]: There has been research showing that prostaglandins series 1 and 3 have an anti inflammatory effect which can help with endometriosis. Nutrition can also help to boost the immune system, which is important if endometriosis is an auto-immune disorder.
|3.75 mg [[Intramuscular injection|intramuscularly]] once per month OR
** Avoid coffee and alcohol. Both can increase the levels of estrone.
11.25-mg depot injection every 3 months
** In many cases, [[cannabis (drug)|marijuana]] ([[cannabis sativa]]) has proven to relax or suppress the pain and relieve stress. Although doctors consider this to be an unorthodox method given all the treatments available for this condition and the fact that it may not produce any long term effects, this may still be an effective way to combat endometriosis. Research on this method is minimal since the drug is illegal in many countries.
| rowspan="4" |
*Down-regulation of the [[Pituitary gland|pituitary]] resulting in decreased production of [[FSH]] and [[Luteinizing hormone|LH]]
*Reduction in serum [[estrogen]]
*Reduction in serum [[testosterone]] and [[androstenedione]]
*[[Amenorrhea]] is induced in 6 to 8 weeks of therapy
| rowspan="4" |
*[[Hot flushes]]
*[[Vaginal dryness]]
*[[Insomnia]]
*[[Osteopenia]]
*Limited use in large ovarian [[Endometrioma|endometriomas]] and severe disease
|-
|[[Nafarelin|Nafarelin acetate]]
|Nasal spray dose of one spray 200 μg twice a day
|-
|[[Goserelin acetate|Goserelin acetate]]
|3.6 mg every 28 days in a biodegradable [[subcutaneous]] implant
|-
|[[Elagolix|Elagolix]]
|150 mg once daily for up to 24 months or 200 mg twice daily for up to 6 months
|-
|[[Oral contraceptive|Oral contraceptive pills]]
|Low dose [[estrogen]] and high dose [[progesterone]] pills
|Continuous therapy for a duration of 6 to 12 months
|Feedback inhibition of [[FSH]] and [[LH]]
|
*Breakthrough bleeding
*Rupture of large [[endometrioma]]
*[[Weight gain]] and breast tenderness
|-
|Synthetic [[steroid]]
|[[Danazol]] 
|200mg to 400mg orally per day for 6 to 9 months
|Produces a hypoestrogenic and hyperandrogenic effect and induces atrophic changes in the [[endometrium]]
|
*Elevated [[liver enzyme]] levels 
*Reduction in [[HDL Cholesterol|HDL]] and [[Triglyceride|TG's]]
*[[Hirsutism]]
|-
| rowspan="2" |[[Progestogens]] only
|[[Medroxyprogesterone acetate]]
|20 to 30 mg orally per day
| rowspan="2" |Feedback inhibition of [[FSH]] and [[Luteinizing hormone|LH]]
| rowspan="2" |
*Limited use in elderly women
*Limited use in young women with a desire to conceive soon after therapy
*[[Anovulation]]
|-
|[[Medroxyprogesterone acetate (injection)|Depo-medroxyprogesterone acetate]]
|150 mg intramuscularly every 3 months
|-
| rowspan="2" |[[Aromatase inhibitor|Aromatase inhibitors]]<ref name="pmid27095958">{{cite journal| author=Słopień R, Męczekalski B| title=Aromatase inhibitors in the treatment of endometriosis. | journal=Prz Menopauzalny | year= 2016 | volume= 15 | issue= 1 | pages= 43-7 | pmid=27095958 | doi=10.5114/pm.2016.58773 | pmc=4828508 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27095958  }} </ref>
|[[Anastrozole]]
|1 mg once daily
| rowspan="2" |Inhibition of [[aromatase]] expressed in the [[Endometrioma|endometriomas]] resulting in decreased [[estrogen]] levels
| rowspan="2" |
*[[Ovarian cyst|Ovarian follicular cyst]] development
*[[Osteopenia]]
|-
|[[Letrozole]]
|2.5 mg once daily
|}
===Pain Management===
[[Non-steroidal anti-inflammatory drug|Nonsteroidal anti-inflammatory drugs]] are useful for the control of pain and help to control the amount of [[bleeding]] when used in [[Combination therapy|combination]] with [[Oral contraceptive|oral contraceptive pills]].<ref name="pmid28114727">{{cite journal| author=Brown J, Crawford TJ, Allen C, Hopewell S, Prentice A| title=Nonsteroidal anti-inflammatory drugs for pain in women with endometriosis. | journal=Cochrane Database Syst Rev | year= 2017 | volume= 1 | issue=  | pages= CD004753 | pmid=28114727 | doi=10.1002/14651858.CD004753.pub4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28114727  }} </ref>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Latest revision as of 14:15, 17 July 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sogand Goudarzi, MD [2], Aravind Kuchkuntla, M.B.B.S[3]

Overview

The mainstay of therapy for endometriosis is pain management and regression of endometrial lesions. NSAIDs are useful for pain management. There are many therapeutic options available to reduce the size of endometrial lesions. Gonadotrophin releasing hormone agonists and danazol are widely used. Continuous oral contraceptive pill use is also helpful in patients with mild to moderate endometriosis.

Medical Therapy

The treatment of endometriosis is a combination of medical and surgical therapy based on the extent of the disease, the age of the patient, and the desire of the patient to conceive. The primary goal of medical therapy is the symptomatic improvement of pain and regression of the endometrial lesions.[1][2][3]

Drug Class Drugs Duration of therapy Mechanism of Action Side effects of therapy
Gonadotrophin releasing hormone agonists Leuprolide acetate 3.75 mg intramuscularly once per month OR

11.25-mg depot injection every 3 months

Nafarelin acetate Nasal spray dose of one spray 200 μg twice a day
Goserelin acetate 3.6 mg every 28 days in a biodegradable subcutaneous implant
Elagolix 150 mg once daily for up to 24 months or 200 mg twice daily for up to 6 months
Oral contraceptive pills Low dose estrogen and high dose progesterone pills Continuous therapy for a duration of 6 to 12 months Feedback inhibition of FSH and LH
Synthetic steroid Danazol  200mg to 400mg orally per day for 6 to 9 months Produces a hypoestrogenic and hyperandrogenic effect and induces atrophic changes in the endometrium
Progestogens only Medroxyprogesterone acetate 20 to 30 mg orally per day Feedback inhibition of FSH and LH
  • Limited use in elderly women
  • Limited use in young women with a desire to conceive soon after therapy
  • Anovulation
Depo-medroxyprogesterone acetate 150 mg intramuscularly every 3 months
Aromatase inhibitors[13] Anastrozole 1 mg once daily Inhibition of aromatase expressed in the endometriomas resulting in decreased estrogen levels
Letrozole 2.5 mg once daily

Pain Management

Nonsteroidal anti-inflammatory drugs are useful for the control of pain and help to control the amount of bleeding when used in combination with oral contraceptive pills.[14]

References

  1. ↑ Bedaiwy MA, Alfaraj S, Yong P, Casper R (2017). "New developments in the medical treatment of endometriosis". Fertil Steril. 107 (3): 555–565. doi:10.1016/j.fertnstert.2016.12.025. PMID 28139238.
  2. ↑ Benagiano G, Guo SW, Bianchi P, Puttemans P, Gordts S, Petraglia F; et al. (2016). "Pharmacologic treatment of the ovarian endometrioma". Expert Opin Pharmacother. 17 (15): 2019–31. doi:10.1080/14656566.2016.1229305. PMID 27615386.
  3. ↑ Streuli I, de Ziegler D, Santulli P, Marcellin L, Borghese B, Batteux F; et al. (2013). "An update on the pharmacological management of endometriosis". Expert Opin Pharmacother. 14 (3): 291–305. doi:10.1517/14656566.2013.767334. PMID 23356536.
  4. ↑ Mateo Sánez HA, Mateo Sánez E, Hernández AL, Salazar Ricarte EL (2012). "[Treatment of patients with endometriosis and infertility]". Ginecol Obstet Mex. 80 (11): 705–11. PMID 23427639.
  5. ↑ Brown, Julie; Crawford, Tineke J; Allen, Claire; Hopewell, Sally; Prentice, Andrew (2017). "Nonsteroidal anti-inflammatory drugs for pain in women with endometriosis". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD004753.pub4. ISSN 1465-1858.
  6. ↑ Pall, M. (2001). "Induction of delayed follicular rupture in the human by the selective COX-2 inhibitor rofecoxib: a randomized double-blind study". Human Reproduction. 16 (7): 1323–1328. doi:10.1093/humrep/16.7.1323. ISSN 1460-2350.
  7. ↑ Duffy, Diane M.; VandeVoort, Catherine A. (2011). "Maturation and fertilization of nonhuman primate oocytes are compromised by oral administration of a cyclooxygenase-2 inhibitor". Fertility and Sterility. 95 (4): 1256–1260. doi:10.1016/j.fertnstert.2010.12.048. ISSN 0015-0282.
  8. ↑ Bedaiwy, Mohamed A.; Allaire, Catherine; Alfaraj, Sukinah (2017). "Long-term medical management of endometriosis with dienogest and with a gonadotropin-releasing hormone agonist and add-back hormone therapy". Fertility and Sterility. 107 (3): 537–548. doi:10.1016/j.fertnstert.2016.12.024. ISSN 0015-0282.
  9. ↑ Allen, Rebecca; Villavicencio, Jennifer (2016). "Unscheduled bleeding and contraceptive choice: increasing satisfaction and continuation rates". Open Access Journal of Contraception: 43. doi:10.2147/OAJC.S85565. ISSN 1179-1527.
  10. ↑ 10.0 10.1 "DailyMed - MEDROXYPROGESTERONE ACETATE- medroxyprogesterone acetate injection, suspension".
  11. ↑ "DailyMed - AYGESTIN- norethindrone acetate tablet".
  12. ↑ "Menopause and Hormone Replacement - Endotext - NCBI Bookshelf".
  13. ↑ Słopień R, Męczekalski B (2016). "Aromatase inhibitors in the treatment of endometriosis". Prz Menopauzalny. 15 (1): 43–7. doi:10.5114/pm.2016.58773. PMC 4828508. PMID 27095958.
  14. ↑ Brown J, Crawford TJ, Allen C, Hopewell S, Prentice A (2017). "Nonsteroidal anti-inflammatory drugs for pain in women with endometriosis". Cochrane Database Syst Rev. 1: CD004753. doi:10.1002/14651858.CD004753.pub4. PMID 28114727.
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