Hormonal Therapy for Inguinal Endometriosis

Inguinal endometriosis is an infrequent extragenital manifestation of endometriosis. Optimal management involves the radical surgical excision of the lesion, supplemented by hormone therapy. Recent case reports and retrospective analyses have indicated that hormone therapy utilizing gonadotropin-releasing hormone agonist, dienogest, or oral contraceptives is the preferred initial therapeutic approach when the patient declines surgery. Abbreviations: GnRHa: Gonadotropin-Releasing Hormone Agonist, OC: Oral Contraceptives, MR: Magnetic Resonance ARTICLE INFO Received: June 26, 2023 Published: July 14, 2023 Citation: Shiomi Ushida, Satoshi Ichi - go, Hiroshi Takagi, Kazutoshi Matsu - nami, Hazuki Kagawa, Ichiro Kawabata and Atsushi Imai. Hormonal Therapy for Inguinal Endometriosis. Biomed J Sci & Tech Res 51(3)-2023. BJSTR. MS.ID.008118.

Endometriosis is characterized by the presence of endometrio - sis-like tissues outside the uterine cavity [1,2]. It predominantly de - velops lesions in the pelvic gonadal organs and rectovaginal pouch, less commonly affecting the gastrointestinal and urinary tracts, and rarely occurring at distant sites such as the umbilicus and thoracic cavity [3,4]. Inguinal endometriosis, an uncommon presentation of extra-pelvic endometriosis, typically manifests as a tender, fixed in - guinal mass of small size. This condition exhibits changes in mass size and pain that correlate with the menstrual cycle. It is observed in approximately 0.5% of endometriosis cases [5,6]. Surgical inter - vention has been frequently reported as the optimal diagnostic and therapeutic strategy [7-9], and, therefore, there is limited literature on hormonal treatment. Hormonal Treatment (Table 1) provides a summary of reported cases of inguinal endo- metriosis managed through hormonal therapy. Tanaka and Umesaki reported complete remission of catamenial right inguinal pain and right shoulder joint pain associated with extraperitoneal endome - triosis following gonadotropin-releasing hormone agonist (GnRHa) therapy. Several cycles of oral contraceptive (OC) therapy exhibited inadequate effects on her both pain [10]. In a retrospective case se - ries, 8 patients with inguinal endometriosis received hormonal treat- ment without surgery. Dienogest demonstrated pain and swelling improvement in 75% (3 out of 4) cases, although symptoms persisted in one case. Pain improved in 1 out of 4 patients receiving OC thera - py. Among the 3 cases showing no improvement, all experienced per- sisting pain. A small subset of patients did not receive any treatment [6,11]. We encountered a critical case featuring a painful mass in the right inguinal area, particularly during menstrual cycles. Three ad - ministrations of gonadotropin-releasing hormone agonist (1.88mg) with a 4-week interval led to complete remission of inguinal endome- triosis and significant improvement of the ovarian lesion (Figure 1) (manuscript in preparation). Copyright@ : Atsushi Imai | Biomed J Sci & Tech Res | BJSTR. MS.ID.008118. Volume 51- Issue 3 DOI: 10.26717/BJSTR.2023.51.008118 42809 Table 1: Reported cases of inguinal endometriosis with hormonal therapy. No. Patient Age Symptoms Medicine Ref. 1 41 Right inguinal mass and pain Dienogest [11] 2 43 Right inguinal mass and pain Dienogest [11] 3 42 Right inguinal mass and pain Dienogest [11] 4 43 Right inguinal mass and pain Dienogest [11] 5 27 Right inguinal mass and pain OC [11] 6 34 Right inguinal mass and pain OC [11] 7 31 Left inguinal mass and pain OC [11] 8 29 Right inguinal mass and pain OC [11] 9 47 Right inguinal pain and right shoulder pain GnRHa [10] Current case 41 Right inguinal mass and pain GnRHa Figure 1: A. A case of inguinal endometriosis. A 41-year-old woman presented with a painful mass in her right inguinal area, particularly during menstrual cycles. Magnetic resonance imaging (MRI) sagittal images (T2-weighted) revealed a cystic mass (2 by 2 cm) in the right inguinal area (yellow arrow) and an ovarian lesion (white arrow). B. Three administrations of gonadotropin-releasing hormone agonist (1.88mg) with a 4-week interval led to complete remission of inguinal endometriosis and significant improvement of the ovarian lesion.

Theoretically, hormonal therapy, rather than surgical intervention, may be considered the primary choice due to the multifocal nature of endometriosis in most patients [12,13]. In cases of severe inguinal endometriosis where surgery is not desired, the ideal medicinal treat- ment should possess prolonged, curative, and safe properties capable of reducing endometriotic lesions. OC is highly safe medications with minimal adverse effects [14,15], making them a current first-choice option for maintenance therapy after remission-induction. However, OC therapy exhibits a slow onset of action, rendering it unsuitable for rapidly ameliorating symptoms. GnRHa therapy can promptly induce complete remission. Inguinal endometriosis is challenging to identify and often mistaken for more common conditions such as hernias, soft tissue tumors, lymphadenopathy, cysts, granulomas and hydroceles. Catamenial symptoms (e.g., variations in mass size and tenderness) and magnetic resonance (MR) imaging findings can raise suspicion for inguinal endometriosis [4]. Frequently, patients undergo surgi - cal procedures with a preoperative diagnosis of hernia, and endo - metriosis is incidentally discovered or identified through histologic examination [6,16]. Surgical excision may be the treatment of choice for inguinal endometriosis, but hormone medications can alleviate symptoms associated with endometriosis and serve as an alternation for patients who do not want surgery. Copyright@ : Atsushi Imai | Biomed J Sci & Tech Res | BJSTR. MS.ID.008118. 42810 Volume 51- Issue 3 DOI: 10.26717/BJSTR.2023.51.008118 Conflict of Interest The authors declare that they have no conflict of interest.

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