Postoperative hormone suppression had a statistically significant effect in reducing endometriosis recurrence and improving pain, according to a systematic review and meta-analysis published in the journal Human Reproduction Update.
“As surgeons, our primary goal is to make patients feel better. We often do this through surgical management of endometriosis,” said co-author Ally Murji, MD, MPH, Associate Professor of Gynecology at the University of Toronto and on Mount Sinai Hospital in Toronto, Canada. “However, despite our best surgical efforts, it is especially daunting when the disease recurs and patients relapse.”
The authors attempted to assess whether postoperative hormone suppression reduced disease recurrence compared to placebo / expectation management.
The MEDLINE, Embase, Cochrane CENTRAL and Web of Science databases were searched from the beginning to March 2020 for randomized clinical trials (RCTs) and prospective observational cohort studies of pre-menopausal women who underwent conservative surgery and who received a therapies initiated hormone suppression of the following medical measures: combined hormonal contraceptives, progestins, levonorgesterel-releasing intrauterine systems (LNG-IUS) and gonadotropin-releasing hormone (GnRH) agonists.
The review consisted of 17 studies (13 RCTs and 4 cohort studies) with a total of 2,137 patients: 1,189 received postoperative suppression and 948 controls.
The mean follow-up was between 12 and 36 months, with the median results being assessed 18 months after the operation.
Among 14 studies (11 RCTs, 3 cohort studies; 1,766 patients in total), the risk of recurrence of endometriosis in patients who received postoperative hormone suppression was significantly reduced compared to the expected management / placebo: relative risk (RR) 0.41; 95% confidence interval (CI): 0.26 to 0.65.
“However, when we limited the analysis to RCTs only, we found that hormonal suppression consistently reduced the risk of postoperative endometriosis recurrence,” said Dr. Murji opposite Contemporary OB / GYN.
In seven studies (6 RCTs, 1 cohort study; a total of 652 patients), patients who received postoperative hormone suppression achieved significantly lower pain scores compared to controls: Standard Mean Difference (SMD) -0.49; 95% CI: -0.91 to -0.07.
“Our review provides new evidence that post-operative hormone suppression reduces the recurrence and pain of endometriosis,” said Dr. Murji. “This contradicts the last Cochrane review on the subject.”
Although the studies included in the review showed significant heterogeneity, “I am convinced of the results,” he said. “We found that there is only a 4% chance that a future RCT will contradict our results.”
Dr. Murji was surprised at the strength of the effect. “Only eight women would need to be treated with postoperative hormone suppression for at least 6 months to prevent endometriosis from recurring,” he said.
Dr. Murji said it was important for doctors to let their patients know that endometriosis is a chronic condition and that surgery is not a panacea. According to Dr. Murji requires extensive patient consultation prior to surgery to educate patients and meet their expectations. “I offer hormonal suppression for patients who do not want to get pregnant immediately after surgery,” he said. “The plan for postoperative prevention is also formalized preoperatively.”
With the recent pandemic-induced surgical delays in COVID-19, “there is a greater chance of helping patients find the ideal medical treatment option that suits their individual needs to bridge patients to and from their surgery,” he said.
Dr. Murji and his colleagues have found that hormonal contraceptives, progestins, LNG-IUS, and GnRH agonists are consistently effective in reducing pain and disease recurrence.
In particular, the LNG-IUS, which can be deployed under laparoscopic visualization at the time of surgery, “avoids some discomfort / placement issues and provides excellent long-term suppression,” said Dr. Murji.
Dr. Murji is a member of the Speaker Bureau / Advisory Boards of Abbvie, Allergan, Bayer, Hologic and Pfizer.
- Zakhari A., Delpero E., McKeown S. et al. Recurrence of endometriosis after postoperative hormone suppression: a systematic review and meta-analysis. Hum Reprod update. Published online October 6, 2020. doi: 10.1093 / humupd / dmaa033
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