Hormone Therapy Before Endometriosis Surgery

Preoperative Hormonal Therapy – what are the choices?

Key Points

Highlight:

• This study compares the effects of preoperative dienogest (DNG) and gonadotropin-releasing hormone agonist  (GnRHa) on the outcome of women who underwent laparoscopic surgery for ovarian endometrioma.

Importance:

• The administration of DNG, instead of GnRHa, improves symptoms, efficacy, and tolerability for women with endometrioma prior to laparoscopic surgery.

What has been done:

• Women scheduled for laparoscopic surgery were enrolled (n=70) and divided into two groups: (i) DNG (n=35), and (ii) Low-dose sustained-release GnRHa, both received for 4 months preoperatively.
• Preoperative outcomes recorded were pain score associated with endometriosis, measured using a numerical rating scale (NRS), adverse events due to hormonal therapy, and the severity of menopausal complaints (measured using the Kupperman index-KI). These measurements were taken before and after treatment.
• Surgical outcomes examined include total surgical duration, blood loss, and postoperative recurrence of endometrioma.

Results:

• NRS and KI were lower in the DNG group compared to the GnRHa group fter 4 months of preoperative hormonal therapy.
• The incidence of hot flashes was lower in the DNG group as compared to GnRHa. However, the incidence of breast pain and abnormal uterine bleeding was significantly higher in the DNG group.
• Total surgical duration and blood loss were similar in both groups, and ovarian endometrioma did not recur in either group 12 months after surgery.

Limitation:

• A major limitation is that the study did not include a non-treatment control group before laparoscopy.

Lay Summary

Hormonal therapy can be effective for endometriosis, although laparoscopic surgery is required for the frequent drug-resistant symptoms. Laparoscopic surgery can markedly improve endometriosis-associated pain.

The administration of GnRH agonist prior to endometriosis laparoscopic surgery may be beneficial to improve surgical outcomes and is sometimes recommended by some laparoscopic surgeons. However, the real benefit of preoperative GnRH agonist is controversial and needs to be weighed against its potential adverse events caused by reduced serum estradiol levels.

Dienogest (DNG) is a selective progestin that has demonstrated significant effectiveness in reducing painful symptoms associated with endometriosis. A previous study showed that the ovarian endometrioma laparoscopic surgical outcomes in women pre-administered with DNG did not differ much from those administered with GnRH agonists. However, this particular study did not compare potential improvements on symptoms and adverse effects due to the drug administration.

This study by Ozaki et al. from the Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan aimed to investigate whether there are advantages of preoperative DNG as compared to GnRH agonist for women who underwent laparoscopic surgery for ovarian endometrioma. The article was published recently in the "Archives of Gynecology and Obstetrics", where the authors have also examined additional measures on symptoms and adverse effects on top of surgical outcomes.

The study enrolled seventy patients and divided them equally into two groups, one group received DNG for 4 months preoperatively, while the other group received low-dose sustained-release GnRH agonist, for 4 months preoperatively.

Several preoperative outcomes were measured, including pain score associated with endometriosis using the numerical rating scale (NRS), adverse events due to hormonal therapy, and severity of menopausal complaints using the Kupperman index (KI). These measurements were taken before and after treatment. Moreover, surgical outcomes examined include the total surgical duration, blood loss, and postoperative recurrence of endometrioma.

The total surgical duration and blood loss during the laparoscopic surgery were similar between the two groups. However, the data showed that the total NRS (pain score) and KI were lower in the DNG group compared to the GnRH agonist group. The serum estradiol levels at this point were also lower in the GnRH agonist group as compared to the DNG group. Importantly, ovarian endometriomas did not recur in both treatment groups 12 months after the surgery. Therefore, based on these data, the authors have recommended that preoperative DNG, rather than GnRH agonist, may be more beneficial for patients scheduled to undergo endometriosis-related laparoscopic surgery.

Clearly, while these data are suggestive of using preoperative DNG, the study is incomplete because there is a lack of data on a group that had no preoperative treatment. Hence, it is difficult to know if preoperative hormonal therapy is superior to no preoperative hormonal therapy. For women who will receive preadministration of hormonal therapy before laparoscopic surgery for ovarian endometrioma, DNG represents another choice that should be considered when choosing GnRH agonist treatment. Overall, this study suggests that DNG may be valuable and may reduce symptoms associated with endometriosis before surgery.

Research Source: https://pubmed.ncbi.nlm.nih.gov/32661756/