{"paper_id":"4f1eac94-36b3-4e33-9371-af824c064aa5","body_text":"ABSTRACT\nIntroduction\nEndometriosis is a chronic inflammatory estrogen-dependent disease affecting 10% of women worldwide leading to chronic pelvic pain and infertility which may be treated clinically or surgically.\nAreas covered\nCurrent literature was reviewed using the keywords ‘gonadotropin releasing hormone agonists (GnRHa),’ ‘endometriosis,’ ‘infertility’ and ‘chronic pelvic pain.’ Relevant papers prioritizing randomized controlled clinical trials (RCT), systematic reviews, meta-analyses, as well as international guidelines were evaluated.\nExpert opinion\nAvailable options for relieving endometriosis-associated pain include GnRHa, progestagens, and combined oral contraceptives, all of which block menstruation to control symptoms without curing the disease. GnRHa administration decreases pain and symptom recurrence after surgical treatment, but side effects and costs limit its use. Published studies to test its effectiveness in easing endometriosis-associated pain are heterogeneous, consider different outcomes with no long-term results. Drug choice should be individualized considering the side-effect profile, tolerability, costs, risks, and benefits as one size does not fit all. As we wait for the development of an ideal pharmacological agents, GnRHa with an add-back regimen remains a second-line option to alleviate the painful symptoms in women with endometriosis. Endometriosis management should consider the systemic nature of the disease and the complexity involved in the pathogenesis of symptoms.\nArticle highlights\nEndometriosis is a chronic inflammatory disease which should be regarded as a systemic disease that is not restricted to the pelvis.\nVarious questions regarding endometriosis treatment remain and the research gap is huge as current therapies do not treat the disease itself but rather provide symptomatic relief with various side effects.\nThe role of GnRHa in endometriosis has shifted tremendously over the years from first- to second-line option. Despite its efficacy in alleviating endometriosis painful symptoms, the use of GnRHa is limited by its side effects as well as costs. Studies in fact reveal that GnRHa use may result in no pain relief or persistence of pain in quite a few women.\nAvailable studies to test GnRHa ts effectiveness in easing endometriosis-associated pain are rather heterogeneous, consider different outcomes, and do not present long-term results.\nPrescribing an add-back therapy reduces the side-effect burden without interfering with GnRHa effectiveness in alleviating pain in women with endometriosis.\nPre-treatment with GnRHa 3 to 6 months (ultra-long protocol) prior to in vitro fertilization (IVF) so as to improve success rates in terms of live birth rates is not recommended any more.\nA change in endometriosis management is mandatory as current treatments aim at treating pelvic lesions, fail to consider the systemic nature of the disease and the complexity involved in the pathogenesis of painful symptoms and infertility.\nTherefore, future studies should focus on understanding endometriosis biology so that individualized treatment approaches may be developed rather than a symptomatic implant-oriented approach.\nDeclaration of interest\nM M Carneiro declares she has received travel grants and lecture honoraria from Ferring, Organon, Novo Nordisk and J&J.\nThe author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.\nReviewer disclosure\nA peer reviewer on this manuscript has received an honorarium from Expert Opinion on Pharmacotherapy for their review work, but have no other relevant financial relationships to disclose.","source_license":"CC0","license_restricted":false}