Postoperative long-term estro-progestin therapy for endometrioma

Postoperative continuous combined hormonal therapy is recommended to prevent the recurrence of endometriomas.

Key Points

Importance:

• After conservative surgery for endometrioma, pain recurs in up to 40% of patients, and anatomic recurrence occurs in nearly one-third of the cases.

 Highlights:

• Long-term continuous estro-progestin or progestin therapy starting soon after conservative surgery reduces the recurrence risk of endometriomas.

What's done here:

• The Italian research team from Bologna University set up a study to assess the efficacy of postoperative hormonal therapy on the recurrence of endometriomas.
• The retrospective cohort study includes 375 women who underwent laparoscopic endometrioma excision, who followed up at 6, 12 months, and then annually after surgery for 4-16years.
• Most patients used estro-progestins (119 cyclic and 61 continuous), 95 patients used progestins and 100 were non-users.
• Pain, endometrioma recurrence at ultrasonography >10mm in diameter, and the reoperation rate were investigated.

Key results:

• Endometriotic cyst recurrence occurred in 36% of the women (20% of them were bilateral endometriomas) within a median of 8 years.
• Postoperatively the most common symptom to reappear was dysmenorrhea, occurring in 43.2%.
• Multivariate regression analysis revealed that postoperative continuous hormone users had a lower recurrence risk for both endometrioma and symptoms.
• The reoperation rate was 16%, one-third of reoperations occurred in the first year. 75% of the reoperation was for the disease progression and 25% was due to the poor response to medical therapy.
• None of the patients who were reoperated for disease progression started hormonal therapy immediately after the first operation because of pregnancy desire.

Strength and Limitations:

• Retrospective study design.
• Women changing therapies during follow-up was difficult to classify, along with the discontinuation period.
• Progestin users were less compared to the estro-progestin users.
• A long follow-up period (up to 17 years) and a large sample size were the strengths of the study.

Lay Summary

After the removal of ovarian endometriomas, the major concern is the high recurrence rate of symptoms and endometriotic cysts. The estimated recurrence rate of endometriomas is up to 50% at 5 years after surgery. To prevent the recurrence, postoperatively long-term combined or single hormone as progestins are generally advised.

Del Forno and colleagues from Bologna University, Italy planned this retrospective cohort study to evaluate the efficacy of hormone therapy on their collection of 18 years of data. The paper is recently published in the scientific journal named "Gynecologic and Obstetric Investigation".

The authors studied the baseline characteristics of  375 women who underwent laparoscopic complete endometrioma excision, with a minimum 1-year follow-up.  Postoperatively most of the patients used estro-progestins (119 cyclic and 61 continuous), 95 patients used only progestins and 100 were non-users, and the follow-up period was between 4 to 16years. The recurrence of endometrioma by ultrasonography  (> 10 mm) and pain recurrence, along with the time of recurrence, unilateral or bilateral involvement, were recorded.

Authors found that postoperative endometriotic cyst recurrence occurred in 36% (20% being bilateral), within a median of 8 years. The postoperative reappearance of pain was in the form of dysmenorrhea in more than 40% of patients. 

When patients with recurrence were analyzed by multivariate regression statistical analysis, it was found that the postoperative continuous hormone users had a lower recurrence risk for both endometrioma and symptoms. The reoperation rate of endometrioma was 16%, one-third occurred in the first year. 75% of the reoperation was for the disease progression and 25% was due to the poor response to medical therapy.

These results supported the beneficial effect of postoperative long-term combined hormonal therapy for the prevention of recurrence of endometriotic cysts and symptoms in women with endometrioma. The authors underlined the importance of continuous hormonal therapy. Surprisingly postoperative medical treatment with progestins only did not show the same beneficial effect on the recurrence of endometriomas in their study.

Research Source: https://pubmed.ncbi.nlm.nih.gov/33849018/