Severe endometriosis treated with long-term GnRHa : case report

Gonadotrophin-releasing hormone agonist (GnRHa) therapy for endometriosis is rarely used for long periods of time because it leads to decreased bone density and menopausal syn- drome. Here, we describe a patient with severe endometriosis who underwent a colostomy and hysterectomy at a young age and has been on GnRHa therapy for 13 years since the surgery. The patient is a 37-year-old GOPO woman who underwent a colostomy for ileus of the sigmoid colon and rectal endometriosis at the age of 21 years. At the age of 22 years, she underwent total abdominal hysterectomy, choco- late cystectomy, and partial rectectomy. After the surgery, her ovarian endometrioma recurred and ureteral endometriosis developed. She was then started on GnRHa therapy and has been on continuous therapy for 13 years up to the pres- ent. Side effects as such as decreased bone mineral density and menopausal syndrome have not been observed. Although GnRHa therapy is generally not used chronically because of its side effects, it has been possible to use it in this patient over a long period of time by ongoing monitoring for the development of deleterious side effects and adjusting the dose as needed. Key words : endometriosis, ovarian cyst, gonadotropin-releasing hormone

Endometriosis is characterized by the presence of endometrium-like lesions outside the uterine cavity. This condition is an estrogen-dependent disease that occurs in 10% of women of reproduc- tive age and regresses after the menopause or ovariectomy. The main symptoms are pelvic pain, including dysmenorrhea, chronic pelvic pain and deep dyspareunia and infertility. In gynecological practice, gonadotropin- releasing hormone agonist (GnRHa) therapy is often used for endometriosis. Continuous administration of GnRHa leads to downregula- tion of the expression of GnRH receptors and the consequent suppression of luteinizing hormone and follicle-stimulating hormone secretion. The

is a state of low estrogen, so that GnRHa therapy is called pseudo-menopausal therapy. The efficacy of GnRHa therapy against the pain of endometriosis and ovarian endometrioma has been reported,' but because long-term GnRHa therapy may lead to decreased bone mineral density and menopausal syndrome, it is not used for chronic therapy.2°3 There have been recent reports on therapies to reduce the adverse side effects of GnRHa while maintaining its therapeu- tic efficacy, such as "add-back" therapy, which administers small doses of estrogen-progestin, and "draw-back therapy", which administers GnRHa at longer intervals.4,5 To the best of our knowledge, although there are reports of the long-term use of GnRHa using these methods, there is no published report on the use of GnRHa therapy for 10 years or longer without using these methods. In this report, we describe a patient with severe endometriosis who needed a colostomy and Received October 4, 2011 ; Accepted November 18, 2011 ö 워 ö ö Ж ö ö ö Ж ö öö ö Ж ö ö ö ö ö 워 ö ˢ Ж ö ö ö ö 워 Ж ö  원웦웑 Ж Ж ö 웍 웎웦웏웦웒 Ж ö Ж ö 웓 õ õ ô õ ô õ ô õ ô õ ㅤ ô õ ô õ ô õ ô