The role of hormonal treatment after endometriosis surgery

Does postoperative hormonal treatment change the probability of endometriosis recurrence?

Key Points

Highlights:

• Postoperative hormonal suppression decreases both radiological lesion recurrence and pain recurrence in endometriosis patients.

Importance:

• There is still no agreement on if we should use hormonal therapy and if so, what drug to use and how long to use that after endometriosis surgery.
• This recent systematic review and meta-analysis study aimed to reveal the answers to these questions.

What's done here:

• MEDLINE, Embase, Cochrane CENTRAL, and Web of Science Databases have been searched up to March 2020 for prospective observational studies and randomised controlled trials that included pre-menopausal endometriosis patients who had surgery and have data for postoperative follow up either with hormonal therapy or placebo/expectant management.
• The medical therapies applied within 6 months postoperatively including combined hormonal contraception, progestins, androgens, levonorgestrel-releasing intrauterine system, and GnRH agonist or antagonist were accepted.
• Radiographic recurrence such as relapse of an endometrioma, plaque, or nodule on MRI or ultrasound; the clinical pain recurrence, or need for a new surgery was primary outcome.
• The change in the endometriosis-related pain, especially dysmenorrhea, was considered as the secondary outcome.

Key Results:

• 17 studies were suitable for inclusion, 13 randomized clinical trial and 4 prospective studies out of 10 797 articles found in database systems.
• These studies originated from six countries: Italy (10), China (3), Thailand (1), Russia (1), the USA (1) and Japan (1).
• Meta-analysis contained 2137 patients included in the above studies, 1189 had postoperative hormonal therapy while 948 were observed expectantly or were given a placebo.
• Patients under post-operative hormonal therapies were found to be less likely experiencing a recurrence, with a recurrence rate of 0.41 (95% Confidence Interval: 0.26 to 0.65).
• Subgroup analyses resulted in a statistically significant decrease of recurrence only with combined hormonal contraceptives and levonorgestrel-releasing intrauterine system, but not others.
• Patients taking postoperative hormonal therapies also had lower pain scores compared to controls.

Limitations:

• Although the authors have done bias reduction and sensitivity analysis it is not easy to evaluate the literature on behalf of postoperative hormonal suppression therapies regarding the heterogeneity of medications, treatments, timings, and methods used in the studies.

Lay Summary

Postoperative hormonal suppression after endometriosis surgery still does not have a uniform approach.

The meta-analysis study conducted by Zakhari et al. aimed to find a significant answer regarding this burden. They analyzed the database systems including MEDLINE, Embase, Cochrane CENTRAL, and Web of Science databases up to March 2020. They only chose randomized controlled trials or prospective studies mentioning postoperative follow-ups for at least 6 months. Finally, thirteen randomized clinical trial and 4 prospective studies out of 10 797 articles found acceptable for inclusion, and overall contained 2137 patients, 1189 with postoperative hormonal therapy and 948 controls, either observed expectantly or were given a placebo.

The results revealed that administration of hormonal treatment within 6 months after surgery decreased the recurrence rates, that were defined clinically, radiologically, or physically recurring endometriosis lesions or symptoms. The use of combined hormonal contraceptives and levonorgestrel-releasing intrauterine system showed significant decrease of recurrence while progestins and GnRH analogs did not. 

In the discussion, the authors mentioned the lower rate of recurrence noted in patients having undergone complete excision would suggest that "recurrence should  be reactivation or progression of residual disease, rather than newly appearing endometriosis, underscoring the importance of surgical technique" and, the surgical technique being a potential source of bias in studies on post-operative outcomes.

The authors concluded as hormonal treatments may be required to prevent recurrences but the type of the therapy should be individualized.

The article was recently published in "Human Reproduction Update".

Research Source: https://pubmed.ncbi.nlm.nih.gov/33020832/