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Long-acting Contraception for Pain Control in Patients with Endometriosis
Abstract & Commentary
By Alison Edelman, MD, MPH, Assistant Professor, Assistant Director of the Family Planning Fellowship, Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, is Associate Editor for OB/GYN Clinical Alert.
Dr. Edelman is a consultant for Schering-Plough (as an Implanon trainer); she has received no funds from Schering-Plough in the past 12 months.
Synopsis: After 6 months of use, both depot medroxy-progesterone acetate and the contraceptive implant (Implanon®) significantly decreased pain associated with endometriosis.
Source: Walch K, et al. Implanon versus medroxyprogester-one acetate: Effects on pain scores in patients with symptomatic endometriosis — a pilot study. Contraception 2009;79:29-34.
Forty-one women with symptomatic, histologically proven endometriosis (Stages 1-4) were randomized to receive either a contraceptive implant (Implanon®) or depot medroxyprogesterone acetate (DMPA). Women were followed every 3 months to report their dyspareunia, dysmenorrhea, and non-menstrual pelvic pain on a 100 mm visual analog scale (VAS; 0 = no pain, 100 mm = maximum pain). In addition, bleeding patterns and satisfaction were monitored. Prior to treatment, women reported an average pain score of 65 mm and after 6 months, a pain score of 30 mm or, in other words, a mean decrease in pain scores of 68% (95% confidence interval [CI], 53-83) with the implant and 53% (95% CI, 28-79) with DMPA (P = 0.36). In addition, significant improvements in pain scores were seen as early as 3 months of use. Overall, bleeding patterns were similar between the two groups. Equivalent rates of women reported being satisfied or very satisfied with either treatment (implant 57%, DMPA 58%), but a higher proportion of women reported being dissatisfied or very dissatisfied with DMPA (implant 9%, DMPA 32%).
Improvement in pain via surgical and/or medical management is often the main goal of endometriosis treatment. Many contraceptives have additional health benefits beyond their primary purpose of pregnancy prevention. Oral contraceptives, DMPA, and the levonorgestrel-secreting intrauterine device have all been shown to improve pain associated with endometriosis.1-3 Walch and colleagues designed their study to determine if the progestin-only implant provided similar relief to DMPA for women experiencing pain due to endometriosis. Although this study was performed in a small group of women, Walch et al provide compelling evidence for the progestin-only implant as another effective treatment option for pain associated with endometriosis. In addition, unlike surgical treatment, medical treatment with hormonal suppression appears to provide greater long-term pain relief. This particular study demonstrated that pain scores were persistently lower among both DMPA and implant users at 12 months of use.
The contraceptive implant (Implanon) is known for its unpredictable bleeding patterns,4 but the patterns reported in this study were similar between the two treatment groups. The majority of women in both groups reported "prolonged" (more than 14 days of continuous spotting or bleeding in 90 days) and/or "frequent" (more than 5 episodes of spotting or bleeding in 90 days) bleeding. The similarity in bleeding profiles during the study may be due to tracking DMPA's bleeding patterns through its typical 6-9 month "transition" period where we expect more women to have unpredictable bleeding with DMPA use. The authors do report an improvement in bleeding pattern with greater duration of use but do not provide more specific data. We can probably get a better sense of how women reacted to bleeding patterns by looking at participants' satisfaction and reasons for study withdrawal. More women in the implant group were "dissatisfied" with the bleeding pattern but only 2 women withdrew from the study because of bleeding. Overall, more women in the DMPA group reported being dissatisfied with the treatment but not because of the bleeding pattern (i.e., weight gain, mood disorders, etc.).
Both the contraceptive implant and DMPA appear to be reasonable treatment options for pelvic pain due to endometriosis. Extrapolating the findings of this study, women can expect to have their pain decrease by 50% at 6 months of use, but improvements in pain can be seen almost immediately with initiating either treatment. However, improvement in pain may be offset by some minor side effects, which may or may not be tolerable depending on the patient.