Invited review
Newer treatment modalities in endometriosis: systematic review

Endometriosis is a chronic, benign gynecological disorder seen in women of reproductive age. It is characterized by the presence of endometrial gland and stromal tissue outside the uterine cavity and intraperitoneal inflammation. In this article, we review the mechanistic basis of traditional established treatment modalities, focusing on efficacy and adverse effects and adequacy of response and compare them with the newer treatment modalities currently undergoing investigation in human and animal models, including aromatase inhibitors, antiangiogenic agents, tumor necrosis factor-a (TNF-α) blockers, matrix metalloproteinase (MMP) inhibitors, selective progesterone receptor modulators (SPRMs) and selective estrogen receptor modulators (SERMs). Several open-label studies show that aromatase inhibitors are effective in reducing lesion size and alleviating pelvic pain in patients with endometriosis refractory to other treatment modalities. Literature reviewed shows that the antiangiogenic agents seem to be more beneficial in treating early-stage disease, and some research has been done on vascular disrupting agents (VDAs) to potentially treat advanced endometriosis. Vascular disrupting agents, currently in phase I and II clinical trials for cancer treatments, operate by inducing apoptosis of endothelial cells in existing blood vessels. However, the literature reports that the VDA’s may serve as an adjunct therapy following laparoscopic surgery. More research needs to be conducted to further evaluate the selective estrogen and progesterone receptor modulators, ligands, vascular growth factor inhibitors, and immunomodulators in the management of endometriosis.