The effect of anti-rheumatic drugs on endometriosis therapeutic outcomes

The effect of anti-rheumatic drugs on endometriosis therapeutic outcomes

Immunosuppressants to treat endometriosis pain

Key Points


  • The administration of disease-modifying anti-rheumatic drugs (DMARDs) is associated with decreased opioid usage among women with endometriosis.


  • Endometriosis may be described as an autoimmune disease because of the associated abnormalities in T and B cell function and various autoantibodies. Hence, the use of immunosuppressant DMARDs to treat endometriosis (pain?) may be beneficial.

What's done here:

  • This retrospective study aimed to examine if DMARDs affect factors in the postoperative clinical management of endometriosis including the use of hormonal treatments, subsequent ablative surgery, and need for pain management, including opioids, non-steroidal anti-inflammatory drugs, and anti-depressants.
  • Data were reviewed from women with endometriosis who were not treated (n=234) or treated with DMARDs for six weeks or more (n=25) at a single healthcare system in Cleveland, (OH, USA), between 2003 and 2013.


  • There was more use of hormonal treatments and antidepressants among women treated with DMARDs.
  • The frequency of post-diagnostic opioids use was lower among women received DMARDs.
  • It must be noted that two groups were significantly different in age and follow-up time.


  • The study was limited to one hospital and may carry intrinsic bias.
  • Limited information of the type of endometriotic lesions, such as superficial endometriosis, diffuse infiltrating endometriosis, or ovarian endometrioma.
  • The decrease in opioid use does not mean "treatment of the endometriosis" and may rather suggest decreasing the "pain", this should be clarified.

Lay Summary

Endometriosis can be described as an autoimmune disease because the abnormalities associated with T and B cell function and various autoantibodies. Although endometriosis has not been found to associate with some severe autoimmune disorders such as systemic lupus erythematosus, it was reported to relate to inflammatory bowel disease. Regardless, the underlying immune dysfunction leading to endometriosis remains unclear, with the suggestion that the immune cells produce pro-inflammatory factors to enhance the growth of endometriotic implants.

To study whether immunosuppression can relieve endometriosis management, Kotlyar et al. examined the use of disease-modifying antirheumatic drugs (DMARDs) on factors in the post-operative management of endometriosis. These DMARDs include hydroxychloroquine, methotrexate, etanercept, and infliximab. The aim was to examine whether immunosuppressant can affect the course of endometriosis and be a potential treatment option for endometriosis.

This retrospective study was performed at a single healthcare system in Cleveland, OH, USA, between January 1, 2003, and January 1, 2014. All women who were treated with DMARDs had because of pre-existing rheumatologic disease were included if they had undergone DMARD treatment for at least six weeks. Other women with endometriosis were involved in the control group using simple random sampling from patient charts. Specifically, the postoperative use of hormonal treatments, the proportion of women undergoing subsequent ablative surgery, and use of adjunct therapies such as antidepressants, steroids, and opioids after surgery were compared between the two groups.

The results showed that between women who received DMARD and those who did not, there was no significant difference in the proportion of subsequent ablative surgery or hormonal treatment. However, there was a higher frequency of antidepressant and a lower percentage of opioid usages among women who were treated with DMARDs. Opioids sale has been shown to be associated with the risk of death. Therefore any effort to reduce their usage in endometriosis patients may be beneficial. The finding from this study might help to develop new approaches to limit opioid medication among women with chronic pain due to endometriosis. Future research using prospective trial design will be useful to more accurately assess the effect of DMARDs on pain control among women with endometriosis.

Research Source:

immune-suppressant anti-rheumatic drugs treatment


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