the chronicMany doctors use hormonal medications as a first-line treatment for endometriosis. Hormone medication can come in the form of oral contraceptives like birth control pills, progestin-only pills, progestin medicines, and GnRH agonists. While hormonal medications are the most commonly prescribed drugs for endometriosis, they have been shown to not eradicate, stop progression, or improve the disease long-term.
Medical therapy represents only a symptomatic treatment and not the definitive solution to endometriosis lesions that may persist despite different medications, dosages, and duration of the therapy.- Management of Women Affected by Endometriosis: Are We Stepping Forward?
How Do They Work?
In theory, hormonal medication is thought to decrease endometriosis tissue activity by halting or suppressing menses. However, there are several problems with this approach. Although suppressed, the endometriosis is still progressing and growing deeper. Since the disease was never removed, the endometriosis tissue will reactivate once suppression stops and symptoms will return. Unsurprisingly, high recurrence rates of disease are associated with all hormonal medications.
The pill specifically suppresses hypothalamic gonadotropin-releasing hormone (GnRH) and pituitary gonadotropin secretion. These are brain structures that control hormone production. The suppression of these hormones results in luteinizing hormone (LH) suppression. Without LH your ovaries don't get the signal to ovulate. So, no egg is released.
There is a myth, even amongst doctors, that hormonal medications are confined to and only work on the reproductive system. Hormonal medications, including birth control, work on the brain level by suppressing brain structures that control hormone production. The brain stops communicating with the ovaries and in turn the ovaries stop ovulating. You are no longer producing your normal cascade of hormones and synthetic hormones have replaced them. This is important because hormones control and impact functions throughout the entire body and each of these can be affected by synthetic hormones. This also dispels the myth that hormonal medications balance or fix your natural hormones. They do not have this ability. They can only suppress, or shut them off.
It’s important to understand that hormonal contraceptives deliver synthetic hormones to your system that impact every system and every cell of your body. Every cell of your body has receptors for these hormones and just like your natural hormones can elicit changes, so can these synthetic birth control hormones.
How Effective Are Hormonal Medications?
All medical therapy, whether administered as first-line treatment or postoperatively, is associated with high rates of disease recurrence.
Despite the proven ineffectiveness, many doctors continue to offer hormonal medication as an option for the treatment of endometriosis. Few are educated on the risks, side effects, and limitations of hormonal medication and as a result they cannot educate their patients accordingly. Too often patients are not informed that it can only provide symptomatic relief, while the disease will continue to progress, potentially worsening the initial problem. It is important to remember that hormonal medication cannot eradicate the disease, cannot improve fertility, and has shown no effect on adhesions.
In the general healthcare community including at the OB/GYN level, it is taught (and hence practiced) that the most frequent mainstays of treatment are medical suppressives and incomplete surgery. Medication does not eradicate endometriosis, however, and the disease does not simply ‘go away’ as a result of drug suppression. At best, such a course of therapy provides only a temporary means of symptom improvement, not definitive treatment. Often, side effects are significantly negative and intolerable, and may last far beyond the cessation of treatment. Poor outcomes on suppression therapies are routine: drug therapy that can destroy endometriosis permanently has yet to be discovered. Hormonal suppression has 'no effect on adhesion of endometriotic cells and cannot improve fertility'.
In a recent review of hormonal contraceptives used for endometriosis-related symptoms, certain ones were found to relieve some symptoms, such as pelvic pain, dysmenorrhoea, and dyspareunia. Due to insufficient evidence, no definitive conclusions could be made about the overall superiority of any particular hormonal contraceptive. However, after a systemic review of the evidence, the supportive data was determined to be of low quality or insufficient to reach conclusions on the efficacy of hormonal contraceptives for treating endometriosis symptoms. Further studies are needed to clarify what place, if any, hormonal contraceptives have in the management of endometriosis.
Data indicate that little difference exists in effectiveness of the various analogs, all of which last only while the patient is undergoing treatment, and most of which have negative side effects.
After reviewing 16 trials, The Cochrane Library found insufficient evidence to determine if there was a benefit from pre-surgical hormone medication. They also found there was no evidence of benefit associated with post surgical hormone medication.
The available literature suggests that Combined Hormonal Contraceptive (CHC) treatment is effective for relief of endometriosis-related dysmenorrhea, pelvic pain, and dyspareunia; however, the supportive data are of low quality. Furthermore, insufficient data exist to reach conclusions about the overall superiority of any given CHC therapy, and the relative benefit in comparison to other approaches. Additional high-quality studies are needed to clarify the role of CHC agents and other treatments in patients with endometriosis-related pain.
What Are the Side Effects?
On the other hand, we do know that hormonal medications can cause intolerable and significant side effects including stroke, Crohn's disease, and certain cancers, including brain, breast, and liver cancer. Other side effects include depression, an increased risk of cardiovascular disease, and an impairment in the ability to recognize others’ emotional expressions. Early research has shown that by altering the hormonal chemistry of the body with birth control it might change users' behaviors and impact mate selection. Studies have shown that it can lead to nutrient deficiencies, increase the risk of developing certain autoimmune diseases, and negatively impact your adrenal and thyroid health.
Headache, persistent pain, pelvic inflammatory disease (PID), life-threatening infection, blood clots, liver tumors, ovarian cysts, mood changes, weight gain, loss of scalp hair, and less sexual desire are potential side effects listed in the medical brochures for Yasmin, Mirena, Depo-Provera, and NuvaRing. This is not an exhaustive list of side effects. The amount of potential side effects of hormonal medications is staggering and varies greatly patient to patient. Side effects can last permanently or long after cessation of the medication.
Orilissa (elagolix)
The newest hormonal drug, Orilissa, has received largely negative reviews from studies, experts, and patients. For example, the Institute for Clinical and Economic Review found that there are limitations in the evidence on the long-term safety and effectiveness of elagolix for use in endometriosis patients. Further studies are needed to confirm if there is any benefit to using elagolix instead of the currently used hormonal medications. Additional studies are also needed to rule out any long-term safety risks for patients. Known risks of elagolix include bone mineral density loss that is significantly greater than with no treatment, changes in blood lipid profiles that may put users at higher risk for cardiovascular events, suicidal ideation, and elevated liver function tests. Here is a searchable database of FDA Adverse Event Cases for elagolix.
Evidence was not adequate to determine whether elagolix offers a net health benefit compared to no treatment, or compared to treatment with either a GnRH agonist (leuprorelin acetate) or a hormonal contraceptive (depot medroxyprogesterone), due to limited and mixed evidence on clinical effectiveness and potential risks. Since endometriosis-related symptoms recur after stopping treatment, it remains to be determined whether elagolix is safe or effective for long-term use.
Lupron
GnRH antagonists such as, Zoladex, Lupron, and Diphereline are commonly used in endometriosis care. These medications were originally approved for treatment of advanced male prostate cancer. Lupron has a controversial history of significant and long-lasting side effects. There have been numerous lawsuits launched by patients who claim the drug is responsible for a wide range of chronic symptoms, including bone loss, memory loss, vision loss, and chronic pain. Dr. Redwine has noted that Lupron does not induce a normal state of menopause and creates an unnaturally elevated FSH.
Lupron's creator, AbbVie has been reprimanded for not investigating deaths in association with several of its drugs, including Lupron. In 1999, the FDA received adverse drug reports about Lupron from 4,228 women, 325 of which required hospitalization and 25 of which died. Patients have filed nearly 24,000 reports for adverse reactions and thousands of deaths from Lupron to the FDA. The FDA deemed more than half of them serious cases and is evaluating them for regulatory actions.
Resources
For more information on hormonal medications and hormonal health, please explore these resources:
- Dr. Jolene Brighten is a Functional Medicine Naturopathic Physician and women's health expert. We've recommended her book, which has been called the Period Bible by readers. Also, check out her Instagram for daily hormonal health information, lifestyle, and nutritional advice.
- Dr. Lara Briden is a Naturopathic Doctor and women's health expert. She offers excellent insights on hormonal health, contraceptive side effects, and holistic solutions for period problems. We highly recommended her book.
- 14 Ways Birth Control Pills Rob Us of Our Health explores ways in which birth control negatively impacts users' health.
- The Strange Truth About the Pill examines the history of birth control and some of the lesser-known facts about its side effects.
- The Contraception Guide provides information on which contraceptives are available today, when you can start taking birth control, whether contraceptives are safe, and what exactly emergency contraception is.
- The Bitter Pill: Why Isn’t Birth Control Better? critically examines the side effects of birth control and shows the impacts on patients' lives and health.
- Can Birth Control Affect Who You’re Attracted To? discusses the possible ways in which birth control may impact users' preference when selecting a mate and potential effects on the brain.
- The Surprising Link Between Women’s Brains and The Birth Control Pill by Sarah Hill, a research psychologist, will teach listeners about what science knows about the pill and the brain, empowering women to make informed health choices.
- Hormonal Birth Control Is A ‘Guessing Game.’ You’re Not Making Up The Side Effects looks at the reports of 85 women to understand the impacts of the many and varied side effects of birth control.
- Beyond the Pill: A 30-Day Program to Balance Your Hormones, Reclaim Your Body, and Reverse the Dangerous Side Effects of the Birth Control Pill brings together up to date research, relevant science, and clinical expertise to create one of the most informative reads on hormones and hormonal contraceptives.
- Period Repair Manual: Natural Treatment for Better Hormones and Better Periods is a compilation of everything that works for hormonal health. How to come off hormonal birth control, what your period should be like, how to talk to your doctor, and treatment protocols for all common period problems, including endometriosis.
- This Is Your Brain on Birth Control uncovers the known effects of birth control on the brain.
- Sweetening The Pill or How We Got Hooked on Hormonal Birth Control details the history of the pill through a feminist lens.
- Fix Your Period: Six Weeks to Banish Bloating, Conquer Cramps, Manage Moodiness, and Ignite Lasting Hormone Balance is a life-changing step-by-step natural protocol to achieve lasting hormone balance and improve everything from PMS, period pain, and heavy periods to irregular cycles and missing periods.
For the next article in the Endometriosis Series, see Complementary and Alternative Therapies for Endometriosis