title: Medical treatment of ureteral obstruction associated with ovarian remnants and/or endometriosis: report of three cases and review of the literature.
abstract: OBJECTIVE
  Experience with low-dose intermittent danazol or prolonged gonadotropin-releasing hormone agonist (GnRH-a) with and without add-back therapy in endometriosis-associated ureteral obstruction.
  
  
  METHODS
  Retrospective case series (Canadian Task Force classification II-2).
  
  
  METHODS
  University-affiliated teaching hospital.
  
  
  METHODS
  Three women with endometriosis-associated ureteral obstruction.
  
  
  METHODS
  The regimen of GnRH-a alone or with add-back included (1) leuprolide acetate 3.75 mg intramuscularly monthly; (2) micronized 17α-estradiol 1 mg/day by mouth; (3) pulsed norethinedrone 0.35 mg/day by mouth, 2 days on and/or 2 days off; and (4) letrozole 2.5 mg by mouth for the first 5 days of the first GnRH-a injection. Danazol, 100 mg/day by mouth, was prescribed as a regimen of 3 months on, 3 months off, for 4 years.
  
  
  RESULTS
  The first case was a 50-year-old woman, gravida 3, para 3, body mass index (BMI) 27 kg/m(2), with multiple surgeries, including hysterectomy and bilateral salpingo-oophorectomy (HBSO), and history of a stroke. She presented with right-sided pain and hydro-uretero-nephrosis. Magnetic resonance imaging identified a right adnexal cyst (4.5 × 3.4 × 2.4 cm). She was treated with leuprolide acetate monthly injections and a ureteric stent. The cyst, pain, and hydro-uretero-nephrosis resolved after 12 months. The second case was a 45-year-old woman, G2P2, BMI 28 kg/m(2) with multiple surgeries, including HBSO. She presented with left-sided pelvic pain. Ultrasound identified a left adnexal cyst and hydronephrosis. After 3 months of leuprolide acetate and add-back therapy, the cyst, pain, and hydronephrosis resolved. The third case was a 46-year-old woman, G2P2, BMI 25 kg/m(2), who presented with left flank and pelvic pain. Magnetic resonance imaging indicated moderate left hydronephrosis and left adnexal pelvic side-wall involvement with possible endometriosis. Due to many previous surgeries, this patient was a high-risk surgical candidate, and therefore, she was offered medical therapy. After a normal serum liver and lipid profile, she was started on danazol, 100 mg/day for 3 months. After 3 months of therapy, there was complete resolution of the patient's hydronephrosis and pain. She was then advised to continue with a 3-month on, 3-month off regimen. She discontinued the danazol and remained asymptomatic with no recurrence of hydronephrosis at 3 years.
  
  
  CONCLUSIONS
  Low-dose intermittent danazol or GnRH-a alone or with add-back, may be effective long-term therapies in endometriosis-associated ureteral obstruction when surgery is contraindicated, refused, or difficult to perform.
authors.affiliation: Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Western University, London, Ontario, Canada. Electronic address: george.vilos@lhsc.on.ca.
authors.forename: George A
authors.initials: GA
authors.lastname: Vilos
authors.affiliation: Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Western University, London, Ontario, Canada.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Marks-Adams
authors.affiliation: Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Western University, London, Ontario, Canada.
authors.forename: Angelos G
authors.initials: AG
authors.lastname: Vilos
authors.affiliation: Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Western University, London, Ontario, Canada; Department of Obstetrics and Gynecology, King AbdulAziz University, Jeddah, Saudi Arabia.
authors.forename: Ayman
authors.initials: A
authors.lastname: Oraif
authors.affiliation: Department of Obstetrics and Gynecology, Dalhousie University, Halifax, Nova Scotia, Canada.
authors.forename: Basim
authors.initials: B
authors.lastname: Abu-Rafea
authors.affiliation: Division of Reproductivve Sciences, Department of Obstetrics and Gynecology, University of Toronto, and Lunenfield-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada.
authors.forename: Robert F
authors.initials: RF
authors.lastname: Casper
mesh_terms: D018931:Antineoplastic Agents, Hormonal / Q000008:administration & dosage*; D002170:Canada; D003613:Danazol / Q000008:administration & dosage*; D004715:Endometriosis / Q000601:surgery*; D004965:Estrogen Antagonists / Q000008:administration & dosage; D005260:Female; D007987:Gonadotropin-Releasing Hormone / Q000819:agonists; D006801:Humans; D006869:Hydronephrosis / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology; D008875:Middle Aged; D010053:Ovary / Q000473:pathology; D011183:Postoperative Complications / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D012189:Retrospective Studies; D000267:Tissue Adhesions / Q000150:complications; D016896:Treatment Outcome; D014517:Ureteral Obstruction / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology
chemical_list: D018931:Antineoplastic Agents, Hormonal; D004965:Estrogen Antagonists; D007987:Gonadotropin-Releasing Hormone; D003613:Danazol
keywords: Add-back therapy; Chronic pelvic pain; Danazol; Endometriosis; GnRH-a; Hydronephrosis; Ovarian remnant syndrome; Ureteral obstruction