Quality of life in women with deep infiltrating endometriosis and combined oral contraceptives

Between 6% and 10% of women overall—and up to 50% of infertile women—experience some degree of endometriosis.1 Combined oral contraceptives have been used for decades to treat typical endometriosis, but researchers wanted to examine just how much these medications could help, and what benefit they could provide to women with more severe forms of endometriosis.

The study, published in the Cochrane Database of Systemic Reviews¹, focused on women with deep infiltrating endometriosis. Endometriosis develops when endometrial tissue extends into areas where it does not belong. In many cases, this tissue is confined to parts of the uterus,2 but with deep infiltrating endometriosis this tissue can move into the bowel or bladder.³

The study focused on women with this degree of endometriosis both with or without involvement of the uterine wall (adenomyosis). Both adenomyosis and endometriosis can cause significant symptoms like chronic pelvic pain, pain during intercourse, and ovulation and menstruation abnormalities.³

A 2018 study addressed the question of whether oral contraceptives really work to effectively treat endometriosis and control pain, but results were somewhat inconclusive.4 While pain scores in women treated with oral contraceptives improved in this study, the research team suggested that larger, more comprehensive studies were needed to really determine the benefit of oral contraceptives in treating endometriosis over other interventions.

Combined oral contraceptives have been used decades to treat many forms of endometriosis as a way of suppressing ovulation and menstruation, with low-dose estrogen varieties usually being the first choice for treatment. Many studies in the past, however, have looked at the effect of these medications through a post-surgical lens, the research team notes. Research supports a positive effect of combined oral contraceptives on pain, sexual function, and quality of life in women who have endometriosis after a surgical procedure, but there is really no data on how these medications affect women who have not have—or do not need—surgery.

Increasing research on newer, third-generation progestins, along with concerns about the effects of oral contraceptives on sexual quality of life led the researchers in this study to question exactly how contraceptive therapy for endometriosis with and without adenomyosis impacts the long-term sexual quality of life and overall health of women with these conditions.¹

There were no serious adverse events reported in the study, and few side effects—mainly headaches, breast tension, and changes in menstrual patterns. At baseline, the study ranked women who suffered from deep infiltrating endometriosis (DIE) with adenomyosis (AD) at the top of pain scale, followed by women with DIE but no AD. Over the 12-month follow-up period, women in both groups reported improvements in all of their clinical symptoms, sexual quality of life, and even other aspects of physical and mental health.

In most cases, combined oral contraceptives are effective at reducing or eliminating pain in 90% of endometriosis patients, the study explains, and several types of progestins like drosperinone and dienogest are shown to be both effective and well-tolerated. In this study, however, researchers used a combination of 2 mg dienogest and 30 mg ethinyl estradiol because of its low cost and tolerability among patients. The inclusion of estroprogestin therapy instead of progestogen therapy alone is important, according to the research team, because it can reduce pain while still maintaining a good sexual quality of life.¹ Researchers also used a flexible extended regimen instead of a conventional schedule, suggesting that clinicians tailor treatment regimens around the individual needs and responses of their patients.

There is room for more research into what doses are most effective without compromising sexual quality of life, according to researchers, but there has been little study on the effect of continuous or flexible combined oral contraceptive therapy on the sexual quality of life in health women—let alone those with conditions that can lead to further difficulty.

References

1. Alcalde AM, Martínez-Zamora MÁ, Gracia M, et al. Assessment of Quality of Life, Sexual Quality of Life, and Pain Symptoms in Deep Infiltrating Endometriosis Patients With or Without Associated Adenomyosis and the Influence of a Flexible Extended Combined Oral Contraceptive Regimen: Results of a Prospective, Observational Study. J Sex Med. 2021 Dec 30:S1743-6095(21)00791-8. doi: 10.1016/j.jsxm.2021.11.015.
2. https://www.jsm.jsexmed.org/article/S1743-6095(21)00791-8/fulltext
3. MedlinePlus. Endometriosis. January 14, 2022. Accessed January 19, 2022.
   https://medlineplus.gov/endometriosis.html
4. Brighman & Women’s Hospital. Deeply infiltrated endometriosis. Accessed January 19, 2022.
   https://www.brighamandwomens.org/obgyn/infertility-reproductive-surgery/endometriosis/deeply-infiltrative-endometriosis
5. Brown J, Crawford TJ, Datta S, Prentice A. Oral contraceptives for pain associated with endometriosis. Cochrane Database Syst Rev. 2018 May 22;5(5):CD001019. doi:10.1002/14651858.CD001019.pub3.
   https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001019.pub3/full