Pharmacists play a crucial role in managing symptoms of endometriosis

Endometriosis affects between 2% and 10% of women between the ages of 25 and 40 in the United States, but as with many conditions, specifically affecting women, clinical research is woefully underfunded. In 2019, only $13 million in federal funds was allocated to endometriosis research, joining the Endometriosis Foundation of America, despite 1 in 10 women living with the disease.¹

The inflammatory disease causes the uterine lining to grow outside the uterus due to estrogen, in places such as the ovaries, fallopian tubes, and pelvic cavity, and even in abdominal areas such as the intestine and bladder.² Often painful, endometriosis can seriously affect quality of life and lead to infertility,^2.3 and it was associated with a 34% increase in stroke risk.^4.5

Like research, available endometriosis treatment options are lacking. Treatment targets typically include pain management and reduction of endometrial growth; in some cases, surgery is necessary. The type of treatment depends on whether or not you want to have children, the age of the patient, and the severity of the symptoms and disease.²

ENDOMETRIOSIS AND AUTOIMMUNE DISEASE

Although not considered an autoimmune disease, the association between endometriosis and autoimmune diseases was examined in a 2019 meta-analysis published in Human Reproduction Update.⁶ Study researchers identified associations between endometriosis and inflammatory bowel disease (IBD), systemic lupus erythematosus (SLE), Addison’s disease, Sjögren’s syndrome (SS), multiple sclerosis plaque (MS), rheumatoid arthritis (RA), autoimmune thyroid disorders and celiac disease⁶ but “only 5 of 26 studies were able to provide high-quality evidence, and of these, 4 supported a statistically significant association between endometriosis and at least 1 autoimmune disease”. The results of this research underscore the need for providers to remain aware of autoimmune disease as a comorbidity. Endometriosis is also associated with inflammation. A 2016 study published in Frontiers in Biosciences found that “inflammation is crucial in the pathogenesis of endometriosis”.⁷ A key cytokine, tumor necrosis factor-α, plays an important role in endometrial inflammation, which can lead to endothelial dysfunction.⁷

AVAILABLE TREATMENT OPTIONS

According to Veronica Vernon, PharmD, assistant professor of pharmacy practice at Butler University College of Health Sciences and Pharmacy in Indianapolis, Indiana, pharmacists play a key role in helping patients manage endometriosis. For patients taking pharmacological therapy, including nonsteroidal anti-inflammatory drugs (NSAIDs), hormonal contraception, and gonadotropin-releasing agent (GnRH) antagonists/agonists, pharmacists can help manage side effects and monitor symptoms.

“Pharmacists can also … raise awareness of the condition and advocate for patients,” Vernon added. “Many patients feel rejected by family, friends, and healthcare providers when discussing their symptoms of endometriosis.” Results of a survey conducted by the Endometriosis Alliance, Vernon noted, found that up to 90% of patients were fired when discussing their pain, and 42% were fired by a provider. health care.⁸

These patients can turn to pharmacists for recommendations on pain relief. “Dysmenorrhea can be a common reason people seek self-care, and pharmacists can help determine if someone needs an evaluation for endometriosis or another secondary form of dysmenorrhea,” Vernon said. .
NSAIDs such as ibuprofen or naproxen are often recommended as first-line treatment for pain, but sometimes prescription painkillers are needed. NSAIDs should be used with caution due to cardiovascular and gastrointestinal risks.⁹ It is recommended to use the lowest possible dose and patients allergic to aspirin should avoid taking NSAIDs.⁹ Pain management is also necessary for patients whose endometriosis requires surgery. Several hormonal treatments can be used to treat pain and reduce symptoms. GnRH drugs can significantly reduce pelvic pain^ten and prevent ovulation. In 2018, Elagolix (Orilissa) – a GnRH antagonist¹¹— became the first FDA-approved oral treatment for moderate to severe pain associated with endometriosis in more than a decade.¹² To prevent bone loss, the low-dose version (150 mg) should only be taken for 24 months; the high-dose version (200 mg) should not be taken for longer than 6 months.¹²

Oral contraceptives can also be used to treat endometriosis to reduce growth and relieve pain. However, pain relief often goes away when treatment is stopped, and side effects of this treatment include breakthrough bleeding, bloating, and weight gain.

In August 2022, the FDA approved relugolix 40mg, estradiol 1mg, and norethindrone acetate 0.5mg (Myfembree),¹³ a once-daily tablet to treat the pain of moderate to severe endometriosis that can be used for 2 years. Its effectiveness has been supported by 2 clinical studies, the results of which have been published in The Lancet.¹⁴ It should be noted with this drug the list of possible side effects including stroke and pulmonary embolism, mood disorders and suicidal ideation, high blood pressure, liver damage, alopecia, etc. Patients should not use hormonal contraceptives while taking this medication.¹³

A 2022 study published in Cannabis and Cannabinoid Research found that during the COVID-19 pandemic, patients increasingly turned to cannabis use to treat endometriosis when access to healthcare was limited. .¹⁵ The results of another study, published in PLOS One,¹⁶ found that cannabis can be effective against pelvic pain, moodiness, and gastrointestinal issues, “with different efficacy depending on the method of ingestion.”¹⁶ As more states legalize cannabis products, pharmacists should ask patients if they are using this form of treatment alone, which may pose fewer risks than long-term use of NSAIDs and other medications. The researchers of the study published in PLOS One called for further study of this promising treatment.

“Understanding the drugs used to treat endometriosis will allow pharmacists to better care for patients,” Vernon said. “It is essential that pharmacists advocate for their patients with endometriosis by recognizing their symptoms and validating them.”

The references

1. Endometriosis Foundation of American: Our Commitment to Research. American Endometriosis Foundation. Accessed February 13, 2023. https://www.endofound.org/research

2. Fourquet J, Sinaii N, Stratton P, et al. Characteristics of women with endometriosis from the United States and Puerto Rico. Endometrial pelvic pain disorder J. 2015;7(4):129-135. doi:10.5301/i.5000224

3. Endometriosis. National Institute of Child Health and Human Development of the National Institutes of Health (NIH). Updated February 21, 2020. Accessed February 2, 2023. https://www.nichd.nih.gov/health/topics/endometriosis

4. Science update: Endometriosis linked to increased risk of stroke, NIH-funded study finds. Eunice Kennedy Shriver National Institute of Child Health and Human Development. Published July 27, 2022. Accessed February 13, 2023. https://www.nichd.nih.gov/newsroom/news/072722-endometriosis-stroke

5. Farland LV, Degnan WJ 3rd, Bell ML, et al. Laparoscopically confirmed endometriosis and risk of stroke: a prospective cohort study. Stroke. 2022;53(10):3116-3122. doi:10.1161/STROKEAHA.122.039250

6. Shigesi N, Kvaskoff M, Kirtley S, et al. The association between endometriosis and autoimmune diseases: a systematic review and meta-analysis. Hum Reprod Update. 2019;25(4):486-503. doi:10.1093/humupd/dmz014
7. Jiang L, Yan Y, Liu Z, Wang Y. Inflammation and endometriosis. Before Biosci (Landmark Ed). 2016;21(5):941-948. doi:10.2741/4431

8. The Endometriosis Alliance survey reveals actions needed to improve the endometriosis patient experience. Press release. The Endometriosis Alliance. November 30, 2021. Accessed February 13, 2023. https://www.prnewswire.com/news-releases/the-alliance-for-endometriosis-survey-reveals-actions-needed-to-improve-the-endometriosis-patient-experience-301431226.html

9. Vonkeman HE, van de Laar MA. Nonsteroidal anti-inflammatory drugs: adverse effects and their prevention. Semin Arthritis Rheum. 2010;39(4):294-312. doi:10.1016/j.semarthrit.2008.08.001

[ PubMed ]10. Rafique S, DeCherney AH. Medical management of endometriosis. Clin Obstetrics Gynecol. 2017;60(3):485-496. doi:10.1097/GRF.000000000000029211. Features to consider. Orilissa. Accessed February 13

11. Features to consider. Orilissa. Accessed February 13, 2023. https://www.orilissa.com/hcp/about-orilissa/mechanism-of-action

12. AbbVie receives US FDA approval for Orilissa (elagolix) for the management of moderate to severe pain associated with endometriosis. Press release. AbbVie. July 24, 2018. Accessed February 13, 2023. https://news.abbvie.com/news/abbvie-receives-us-fda-approval-orilissa-elagolix-for-management-moderate-to-severe-pain-associated-with-endometriosis.htm

13. Myovant Sciences and Pfizer receive US FDA approval for MYFEMBREE, a once-daily treatment for the management of moderate to severe pain associated with endometriosis. Press release. Myovant Sciences. August 5, 2022. Accessed February 2, 2023. https://investors.myovant.com/news-releases/news-release-details/myovant-sciences-and-pfizer-receive-us-fda-approval-myfembreer

14. Giudice LC, As-Sanie S, Arjona Ferreira JC, et al. Combination oral relugolix once daily versus placebo in patients with pain associated with endometriosis: two phase 3 repeated, randomised, double-blind studies (SPIRIT 1 and 2). Lancet. 2022;399(10343):2267-2279. doi:10.1016/S0140-6736(22)00622-5

15. Armor M, Sinclair J, Cheng J, et al. Endometriosis and cannabis use during the COVID-19 pandemic: an international cross-sectional survey. Cannabis Cannabinoid Res. 2022;7(4):473-481. doi:10.1089/can.2021.0162

16. Sinclair J, Collett L, Abbott J, Pate DW, Sarris J, Armor M. Effects of cannabis ingestion on endometriosis-associated pelvic pain and associated symptoms. PLoS One. 2021;16(10):e0258940. doi:10.1371/journal.pone.0258940