Synarel and Zoladex are similar agents both acting at the level of the brain to suppress ovarian function and thus elicit a menopausal type status. The resulting low oestrogenic state does have some temporary benefits in relation to the suppression of endometriosis. The problem however is that for many people the menopausal type symptoms are substantial and the vast majority of people do not enjoy being on these agents. Many patients who have had endometriosis surgery are often told that they should then have a course of either Synarel or Zoladex to “dry up the endometriosis” and then the surgeon will suggest a period of “seeing how things go”. Whilst this is a common strategy and I see many patients who have taken these agents in the past it is difficult to understand the rationale of this therapeutic maneuver. I would liken it to what other professions refer to as the “Mortein” treatment. (For those outside Australia, Mortein is a type of fly spray, the “treatment” being a “buzz off “or “go away” effect).
The consequence of being in a hypo-oestrogenic state for a considerable period is such that osteoporosis is a distinct possibility. For this reason it is recommended that the therapy not be used for greater than 6 months. Additionally these agents are clearly contraceptive. It is possible to use so called “add back” therapy to dribble a small amount of oestrogen back thus hopefully decreasing these long term risks of osteoporosis although it strikes me that the vast majority of patients are not interested for understandable reasons in such a regime. I rarely see patients who would be comfortable continuing on this regime and it seems to be of academic interest rather than a pragmatic solution.
I fail to understand why this strategy should be used at all. At the completion of the 6 months and having experienced the side effects over those months the situation will then rapidly return to exactly the same as before and further treatment will then be required. I strongly believe that much of the use of Synarel and Zoladex in the post-laparoscopy setting where endometriosis has been identified is a form of cop-out by the surgeons. Whilst they have clearly appreciated that there is a problem they are then unable to deal with that problem and simply suggesting GnRH analogues has the effect of buying time for them but there is no rational reason why the situation will improve or resolve. I see large numbers of patients in my practice who have either used or had these agents recommended. In my eyes the only good from this knowledge is that it is likely that the particular individual will have reasonably significant underlying endometriosis. These particular patients I find do extremely well as both we and others have shown that if you have substantial disease and if it is adequately removed in an excisional fashion and then steps are taken in a much more moderate way with either pregnancy or some minor form of hormonal suppression such as the use of Mirena the vast majority of patients have dramatic improvements. The more difficult situation involves those individuals who have had Synarel where endometriosis can then be not identified. Presumably some of these people may have very minor degrees of disease whilst others will have alternative issues such as adenomyosis.
There have been reports in the literature and in the Cochrane database to suggest that the use of Synarel or Zoladex as a long down regulator prior to IVF may be advantageous in patients with significant endometriosis. I would caution these strategies on a number of issues. Firstly these people are already like to have a low AMH and further suppressing the situation does not seem to be a good idea intuitively. Secondly I believe all of these studies are fundamentally biased as the units involved rarely have the surgical expertise to deal adequately with the problem and therefore surgery has not been utilised as an option. Our data and that of many around the world increasingly is that if you have endometriosis, particularly if it is severe and then excised your pregnancy prospects both spontaneously and following IVF are significantly increased.
For many individuals who have had Synarel or Zoladex suggested after a laparoscopy a second opinion would be an excellent idea. Be wary of “Mortein” treatments.