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Exciting News for Endometriosis:
Aromatase Inhibitors and Ablation

Endometriosis cells are abnormal in 3 ways:

  • They produce abnormally high levels of estrogen
  • They possess abnormally high levels of estrogen receptors
  • They produce abnormal levels of prostaglandins and cytokines (inflammation molecules that cause pain, infertility, and other problems)

Advancing the Treatment for Endometriosis: Aromatase Inhibitors and Ablation

The key for advancing the treatment of endometriosis lies inblack_stepping_stones.jpg finding ways  to selectively eliminate endometriosis cells. One promising new treatment involves “debulking” the endometriosis cells using aromatase inhibitors alone, or if fertility is not desired, combining aromatase inhibitors with endometrial ablation.

Endometriosis: Abnormal Cells Within and Outside the Uterus

Endometriosis implants possess abnormal amounts of an enzyme called “aromatase”. This enzyme converts estrogen-precursor molecules to estrogen. Endometriosis implants also have high levels of estrogen receptors.

For a more complete explanation of the pathophysiology (underlying causes) of endometriosis see related post here.

The endometrium, or uterus lining, also contains abnormal amounts of aromatase and estrogen receptors in women with endometriosis.

Endometriosis: a Self-Perpetuating Process

Endometriosis implants can both synthesize estrogen independent of the ovarian hormones; and they are more sensitive to estrogen. They are analogous to self-sustaining, self-perpetuating machines.

Endometriosis located outside the uterus can re-generate itself and spread through self-stimulation, whether or not the uterus and ovaries are present.

This explains why some women who have hysterectomy for endometriosis have recurrent pain after total hysterectomy. Hysterectomy and oophorectomy (removal of ovaries) “debulks” endometriosis tissue present in the uterus and ovaries, but it does not remove endometriosis implants present outside the uterus.

Aromatase Inhibitors Can Target Endometriosis Located Outside the Uterus

Aromatase inhibitors (AI’s) block the enzyme, aromatase, essential to estrogen production. Thus AI’s can target endometriosis cells anywhere in the body, be they on on nerves outside the uterus, the ovaries, or inside the uterine muscular wall (this type of endometriosis is called “adenomyosis” and is responsible for pain and heavy bleeding with menses).

Early studies indicate aromatase inhibitors have the potential to reduce or eliminate endometriosis for at least as long as Lupron, or even longer, with fewer side effects than either Lupron or total hysterectomy.

Endometrial ablation rids the uterus of abnormal endometrial cells

Global endometrial ablation (GEA) is a procedure to remove the uterine lining in order to treat abnormal uterine bleeding. It can be done in the office in a few minutes and requires no down-time from work. Global endometrial ablation has potential application to endometriosis.

In women with endometriosis who have severe menstrual cramps (dysmenorrhea) endometrial ablation can be used to remove the uterus lining, thus the abnormal cells within that lining. This can have immediate effects on heavy menstrual bleeding and pain.

Global ablation has the potential to reduce the load of abnormal cells in the endometrium, thus reducing the chances of these spreading outside the uterus. In reducing the abnormal cells, global ablation also has the potential to reduce prostaglandins and cytokines, molecules that contribute to pelvic pain.

Using AI’s alone, or in combination with GEA has promise to control endometriosis symptoms without need for surgery or incurring the side effects of Lupron.

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{ 6 comments… add one }

  • Cathryn Deluca February 18, 2011, 6:44 pm

    I am 52 years old and suffer from residual endometriosis
    About four years ago I was diagnosed with a large endometrioma on my right ovary . Since that time I have had a full hysterectomy with ovaries removed and two subsequent surgeries to excise the endo
    A year ago the pain returned , but continues in a cyclical pattern almost mimicking a menstrual cycle , mid month and end of month there is a rise in symptoms. I started natural progesterone and within six weeks my symptoms increased. I was told it should shrink the implants. I have done so much to try to rid myself of the pain, acupuncture physical therapy, yoga, diet and yet this seems to be bigger than I.
    Can progesterone aggravate endo symptoms? I have recently discontinued and how long will it take for the pain to settle down?
    Is there anything in your experience that you might suggest as NEXRAD steps? I am beginning to lose hope.

    Thanking you in advance
    Sincerely Cathryn

    • Shelley Binkley April 4, 2011, 1:38 pm

      Yes, some endometriosis tissue has progesterone receptors, so progesterone can sometimes make endometriosis symptoms worse. Consider the anastrazole discussed on this site, or Lupron, if you haven’t already tried it. Anastrazole blocks production of estrogen and progesterone within the endometriosis cells.

  • rose October 5, 2013, 6:43 pm

    if ive had endometrosis and fibroid tumours is it safe to take an all natural HRT? I am 52 now and had an endometrial ablation last august. My hot flashes and anxiety are wicked, and im scared to take estrogen and protrium. Any other suggestions?

    • Shelley Binkley October 20, 2013, 3:37 pm

      Hi Rose,

      Endometriosis and fibroids both have receptors for estrogen and progesterone. Natural hormones are still estrogen and progesterone. If you have a lot of receptors for these hormones on your endometriosis and your fibroids, you may see a worsening of your symptoms with any hormone treatment, whether or not it is “natural”.

      For bad hot flashes, if you don’t want to take hormones, you my consider black cohash or isoflavones (soy extracts). These are available in health food stores. Some non-hormonal medications, such as the antidepressant venlafaxine (Effexor), can be used to reduce hot flashes.

      -Thank you for reading the blog and commenting. Many people have similar questions to yours so commenting benefits everyone.

      -Dr. B.

  • Sera Miller December 11, 2013, 12:59 am

    Hi Doctor~
    I’m a 29 year-old female, and have been struggling with endometriosis since my menses began (about 11 y.o.) Extreme pain, very heavy bleeding, severe back pain (and even right thigh!) My OBGYN started me on birth control to help my abnormal heavy bleeding, pain, angst and more at 14. For years I tried all the pills – and even had horrible break-through bleeding when the doctors told me to not take the week to allow for a period. When that didn’t bear fruit, the doctors put me on Lupron- for 11 months, and HRT for only a few of those months. I thought I’d lose more than my mind- hair loss, verified veins, weight gain, horrible night sweats, mood swings, diagnosed arthritis, diagnosed osteopenia, one DVT, receeding gum lines, horrible IBS- I aged so rapidly, I feared I’d never bounce back! After all of that, a few months later, all my symptoms returned- along with the creakiness and fragility of my new body. LOADS of Vitamins, Vioxx, Elmeron, Fosamax, Lovenox shots, Coumadin therapy, you name it. It wasn’t until 20 an OBGYN decided to surgically look around and remove any endometrial lesions… She ended closing me up after only a few minutes and referred me to a top team of laparoscopic surgeons in the state. Resection of endometriosis from everywhere- bowel, sacrum, outside of bladder, you name it- endometrial ablation, cystoscopy, resection of spinal nerves that run to uterus, and more. A month later I go in for a check and end up to have new pre-cancerous cervical cells. So I have a colloscopy. Years go by, on birth control again- NuvaRing, etc… Finally, a doctor suggest a total hysterectomy and oopherectomy. I was scared, but was losing hope… First step for insurance, though, was total uterine ablation.
    I haven’t had a period since then- over two years ago- I’ve heard that full ablation cannot cause the body to go into early onset menopause, but is this true even for someone who has gone through a chemically-induced menopause before? And also, I’m concerned about the lesions that are still growing outside my uterus if I’m not in menopause… And I a good candidate for AI’s?
    I don’t want to have a hysterectomy or my ovaries taken out- I don’t heal like I should already, and I can’t take HRT because it gives me blood clots (now 2 DVT’s) AND am afraid that the more surgical procedures I have, the higher risk of infection or messing with the cells- which I’ve heard can attribute to a higher risk of cancers, which both parents, one or more siblings, cousins, and both sets of grandparents have one form of cancer or another.

    Please help me!!! Could it be my hormones that I’m so fragile and haven’t bounced back after 12 years? And could I go through early onset menopause again sooner than later because of the ablation because of the Lupron? And am I a good candidate for AI’s? And do they treat ovarian cysts too?

    Full of questions & true gratitude,

    • Shelley Binkley December 15, 2013, 6:35 am

      Hi Sera,

      Your symptoms could certainly be due to hormone imbalances. AI’s might be beneficial in your situation but I recommend you follow up with your doctor for further evaluation and treatment.

      Thank you for reading the blog and commenting.

      -Dr. B

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