Can postoperative GnRH agonist treatment prevent endometriosis recurrence? A meta-analysis

Pituitary Suppression with Gonadotropin-Releasing Hormone Agonist Prior to Artificial Endometrial Preparation in Frozen-Thawed Embryo Transfer Cycles: A Systematic Review and Meta-Analysis of Different Protocols and Infertile Populations

This study investigates the effect of GnRHa pretreatment on pregnancy outcomes in artificial endometrial preparation for frozen-thawed embryo transfer (AC-FET) cycles. A systematic review of English language studies published before 1 September 2022, was conducted, excluding conference papers and preprints. Forty-one studies involving 43,021 participants were analyzed using meta-analysis, with a sensitivity analysis ensuring result robustness. The study found that GnRHa pretreatment generally improved the clinical pregnancy rate (CPR), implantation rate (IR), and live birth rate (LBR). However, discrepancies existed between randomized controlled trials (RCTs) and observational studies; RCTs showed no significant differences in outcomes for GnRHa-treated cycles. Depot GnRHa protocols outperformed daily regimens in LBR. Extended GnRHa pretreatment (two to five cycles) significantly improved CPR and IR compared to shorter treatment. Women with polycystic ovary syndrome (PCOS) saw substantial benefits from GnRHa pretreatment, including improved CPR and LBR and reduced miscarriage rates. In contrast, no significant benefits were observed in women with regular menstruation. More rigorous research is needed to solidify these findings.

Dienogest in conjunction with GnRH-a for postoperative management of endometriosis

Objective: The aim of this study is to assess the postoperative efficacy of the combined administration of dienogest (DNG) and gonadotropin-releasing hormone agonists (GnRH-a) in patients diagnosed with endometriosis (EMS), while acknowledging the extensive use of DNG in the extended therapeutic management of EMS. Methods: In this retrospective study, a cohort of 154 patients who underwent conservative surgical intervention for EMS were scrutinized. The cohort was stratified into two distinct groups based on their prescribed pharmacological regimens. Group A, 70 patients received postoperative oral administration of DNG at a dosage of 2 mg/day, whereas Group B, 84 patients underwent treatment involving 3 to 4 injections of GnRH-a post-surgery, followed by DNG therapy. Parameters assessed included pelvic pain visual analog scale (VAS) scores, quality of life metrics (EHP-5), and the incidence of adverse reactions within both groups. Results: Both groups exhibited sustained low VAS scores following the prescribed treatments. The predominant occurrence of adverse bleeding patterns manifested predominantly within the initial 6 months of the treatment. Notably, Group B demonstrated a significantly diminished of experiencing frequent and irregular bleeding in comparison to the DNG group (20.0% vs. 8.3%, 12.9% vs. 3.6%, p < 0.05). The administration of GnRH-a did not exacerbate the impact on bone health. Subsequent to health promotion interventions, the incidence of weight gain in both groups declined to 7.1% during the 6-month follow-up (p < 0.05). Group B exhibited a 100% satisfaction rate with the treatment, concomitant with a noteworthy reduction in EHP-5 scores (p < 0.05). Patients with deep infiltrating endometriosis (DIE) nodules displayed marginally higher postoperative VAS scores than their non-DIE counterparts (0.89 ± 0.96 vs. 0.49 ± 0.78). However, with sustained medication use, pain scores within the DIE group exhibited a continual decrease, maintaining a low level of 0.29 ± 0.67 at 12 months and beyond. Conclusion: The short-term adjunctive use of GnRH-a prior to DNG treatment postoperatively in patients with EMS proves efficacious in mitigating early adverse bleeding, enhancing patient adherence, and improving overall quality of life. Notably, this therapeutic approach demonstrates favorable safety profiles and is equally effective in patients with DIE.

Clinical Efficacy, Pharmacokinetics, and Safety of the Available Medical Options in the Treatment of Endometriosis-Related Pelvic Pain: A Scoping Review

BACKGROUND

In this scoping review, we sought to identify published studies evaluating the drugs currently used in the treatment of endometriosis-related pelvic pain, with reflection on their chemical properties, pharmacokinetics, safety profile, and clinical efficacy.

METHODS

A literature search was conducted with the use of the PubMed and EMBASE electronic databases, focusing on identifying articles published in English between January 1990 and 2023.

RESULTS

Based on the included studies, current therapy options for the treatment of endometriosis-related pain identified and reviewed in this article were: (1) non-steroidal anti-inflammatory drugs; (2) combined oral contraceptive (COCs); (3) progestins; (4) gonadotropin-releasing hormone agonists and antagonists; (5) aromatase inhibitors (AIs); (6) selective estrogen and progesterone receptor modulators; and (7) levonorgestrel-intrauterine device.

CONCLUSIONS

Based on the published evidence, clinicians should consider NSAIDs, COCs, and progestins as the first-line medical therapies. Compared with second-line options, such as GnRH agonists/antagonists or AIs, the abovementioned first-line options are well tolerated, efficacious, and exhibit lower overall price. Future research priorities should be to identify novel target therapies and to evaluate the effects of available drugs through different routes of administration.

Efficacy of Post-Operative Medication to Prevent Recurrence of Endometrioma: Cyclic Oral Contraceptive (OC) After Gonadotropin-Releasing Hormone (GnRH) Agonist Versus Dienogest

BACKGROUND

There are several medical treatment options for endometrioma. Progestin, especially dienogest, is an effective drug for preventing recurrence of endometrioma after surgery. Additionally, oral contraceptive (OC) use after conservative surgery has been reported to reduce significantly the risk of endometrioma recurrence. The aim of this study was to compare the long-term effects of gonadotropin-releasing hormone (GnRH) agonist followed by OC to those of dienogest alone to prevent recurrence of endometrioma after laparoscopic surgery.

METHODS

A retrospective cohort study was performed on patients who underwent conservative laparoscopic surgery for endometrioma between January 2000 and December 2020, in the Endometriosis Clinic, Department of Gynecology, Samsung Medical Center. A total of 624 patients who received medical treatment at least six months after laparoscopic conservative surgery for endometrioma was included. Among them, 372 patients used OC after GnRH agonist therapy, and 252 patients used dienogest. Within the OC group, 148 used a 21/7 regiment and 224 used a 24/4 regimen. A cumulative endometrioma recurrence curve was presented using the Kaplan-Meier method to compare the recurrence of those groups.

RESULTS

The cumulative recurrence rate of endometrioma for 60 months was 2.08% (n = 4) in the OC after GnRH agonist group and 0.40% (n = 1) in the dienogest group. There was no statistical difference in cumulative recurrence of endometrioma between the two groups. In subgroup analysis, the cumulative recurrence rate of endometrioma over 60 months was 4.21% (n = 2) in the 21/7 OC group and 1.09% (n = 2) in the 24/4 OC group and showed no significant difference.

CONCLUSION

Long-term use of OC after GnRH agonist as well as that of dienogest treatment are effective postoperative medical therapies for preventing endometrioma recurrence. Thus, the choice of regimen can be individualized or used interchangeably depending on patient condition, need for contraception, and compliance with drug therapy.

A Preliminary Study on the Effects of Black Cohosh Preparations on Bone Metabolism of Rat Models With GnRH-a-Induced Peri-Menopausal Symptoms

BACKGROUND

Endometriosis (EMS) is a relapsing and estrogen-dependent disease. For endometriosis such as deep endometriosis and ovarian endometrioid cysts, surgery is the most effective treatment. Long-term follow-up showed that the recurrence rate of endometriosis after surgical treatment was high, so postoperative drugs were needed to reduce recurrence, and Gonadotropin-releasing hormone agonists (GnRH-a) were the most commonly used drug for postoperative management.GnRH-a may reduce the post-treatment endometriosis relapses by lowering the hormone levels in the body. However, the use of GnRH-a can give rise to perimenopausal symptoms, especially osteoporosis, bone loss, and bone pain, for which reason GnRH-a use is often limited. The add-back therapy is often used to alleviate the untoward effects caused by GnRH-a. However, long-term use of hormone drugs may lead to EMS recurrence, thrombosis, and breast cancer. Therefore, a safer and more effective drug is urgently needed to alleviate the untoward effects caused by GnRH-a. In recent years, scholars at home and abroad have found that isopropanolic Cimicifuga racemosa extract (ICR), as a plant extract, can better relieve the symptoms of perimenopausal women. At the same time, some studies have initially confirmed that black cohosh preparations can relieve the perimenopausal symptoms caused by GnRH-a treatment in EMS patients.

OBJECTIVE

To investigate the effect of black cohosh preparations on the bone metabolism of rat models with GnRH-a-induced perimenopausal symptoms.

METHODS

The rat models of perimenopausal symptoms were established by GnRH-a injection. and normal saline (NS injection) was used as the control. According to the modeling method and drug intervention, the rats were randomly divided into four groups: GnRH-a injection + saline intervention group (GnRH-a + NS), saline injection control + saline intervention group (NS + NS), GnRH-a injection + estradiol intervention group (GnRH-a + E2), and GnRH-a injection + black cohosh preparation intervention group (GnRH-a + ICR). The rat models were identified with the vaginal smear method, and then the corresponding drug intervention was administrated for 28 days. After the intervention, the rats were sacrificed. The rats' bone mineral density (BMD) of the distal femur was detected by a dual-energy X-ray bone density scanner. Rat tibia bone tissues were decalcified and made into slices. The pathological and morphological changes of rat tibial bones in each group were observed through HE staining. Histomorphometry parameters of rat tibial bones in each group, such as trabecular bone volume (TBV), trabecular thickness (TbTh), trabecular number (TbN), and trabecular spacing (TbSp), were detected and analyzed by using an automatic image analysis system.

RESULTS

(1) The BMD level of the distal femur in the GnRH-a + NS group was significantly lower than the NS + NS, GnRH-a + E2, and GnRH-a + ICR groups (P<0.01), the BMD levels in GnRH-a + E2 and GnRH-a + ICR groups were slightly lower than the NS + NS group, but there was no significant difference among the three groups (P>0.05). (2) The pathological changes of the tibia bones under the microscope in different groups were as follows: The tibia bone trabecular structure was normal in the NS + NS group, without trabecular thinning or fracture, and the arch structure was normal. In the GnRH-a + NS group, some trabecular structures tapered, the arch structure disappeared, but no obvious bone fracture was observed in the trabecula. In the GnRH-a + E2 and GnRH-a + ICR groups, the trabecular structures were normal, without trabecular bone thinning or fracture, and the arch structures were normal. (3) The TBV level of the GnRH-a + INS group was significantly lower than that of the NS + NS, GnRH-a + E2 and GnRH-a + ICR groups (P<0.01, P<0.05, P<0.01), while there was no significant difference among NS + NS, GnRH-a + E2 and GnRH-a + ICR groups (P>0.05). (4) The TbTh levels in the four groups had no significant difference (P>0.05). Compared with the NS + NS group, the TbTh levels in the GnRH-a + NS, GnRH-a + E2, and GnRH-a + ICR groups showed a descending tendency, while the TbTh levels in the GnRH-a + E2 and GnRH-a + ICR groups were slightly higher than that of the GnRH-a + NS group. However, such differences were not significant statistically (P>0.05). (5) Compared with the NS + NS group, the TbN levels in the GnRH-a + NS, GnRH-a + E2, and GnRH-a + ICR groups decreased remarkably (P<0.05). Compared with the GnRH-a + NS group, the TbN levels in the GnRH-a + E2 and GnRH-a + ICR groups showed a mild descending tendency, but such differences were not significant statistically (P>0.05). (6) The TbSp level of the GnRH-a + NS group was significantly higher than that of the NS + NS, GnRH-a + E2, and GnRH-a + ICR groups (P<0.01), while there was no significant difference among NS + NS, GnRH-a + E2 and GnRH-a + ICR groups (P>0.05).

CONCLUSION

The GnRH-a injection could achieve the desired effect. GnRH-a injection may lead to the loss of bone mass in rats. Black cohosh preparations, like estrogen, may have a protective effect on bone mass loss caused by GnRH-a injection.

Dienogest and the Risk of Reoperation in Endometriosis

Background: This retrospective cohort study aimed to determine whether there is a difference in reoperation rates between patients who used dienogest (DNG) and patients who did not use DNG. Methods: Using Health Insurance Review and Assessment Service (HIRA) data generated between 1 January 2010 and 30 June 2018, we identified women with an endometriosis diagnosis code who used GnRH agonists after gynecological surgery. Among them, women prescribed DNG were selected as the DNG group, and those who did not receive DNG were selected as the control group. A survival analysis of the reoperation between the two groups was performed. Results: DNG and control groups were extracted from 9735 people each. The reoperation rates were 0.4% and 0.6% in the DNG and control groups, respectively, without adjusting. In the Cox proportional risk analysis, DNG use increased the reoperation rate {hazard ratio (HR), 1.599; 95% confidence interval (CI), 1.005–2.545}. The site of endometriosis and the number of GnRH agonist injections were not associated with reoperation (HR, 1.008; 95% CI, 0.739–1.374; HR, 1.062; 95% CI, 0.690–1.635). In the subgroup survival analysis, according to the period between the last GnRH agonist injection and the first DNG dose, DNG did not increase the reoperation rates up to 9 months (~3 months: HR, 0.968; 95% CI, 0.551–1.699; 4~6 months: HR, 1.094; 95% CI, 0.58–2.063; 7~9 months: HR, 2.419; 95% CI, 0.735–7.962), but DNG increased the reoperation rate from 10 months onwards (10~12 months: HR, 3.826; 95% CI, 1.164–12.579 and ~13 months: HR, 8.436; 95% CI, 4.722–15.072). Conclusions: Women who used DNG had a higher endometriosis reoperation rate than women who did not use DNG. However, the initiation of DNG treatment within nine months after the last GnRH agonist injection did not affect the endometriosis reoperation rate.

Linzagolix: a new GnRH-antagonist under investigation for the treatment of endometriosis and uterine myomas

INTRODUCTION

Uterine myomas and endometriosis are benign hormone-dependent diseases affecting women of reproductive age. Substantial efforts have been made to develop innovative medical options for treating these gynecologic diseases. Elagolix and relugolix have been approved in some countries for treating endometriosis and myomas, respectively; however, linzagolix (OBE 2109, KLH 2109) is a new oral gonadotropin-releasing hormone (GnRH) antagonist in phase II-III trials. Treatment options for women with contraindications for hormonal therapies or who refuse particular options, are the driving force behind the development of new drugs in this area.

AREA COVERED

This drug evaluation highlights definitive and preliminary results from previous and ongoing studies of linzagolix for the treatment of endometriosis and myomas.

EXPERT OPINION

Linzagolix showed a dose-dependent and rapidly reversible action on the pituitary-gonadal axis. In a recent phase II trial (EDELWEISS), linzagolix significantly reduced pain related to endometriosis and improved quality of life at single daily doses of 75-200 mg. The preliminary results of international, double-blind phase III trials (PRIMROSE 1 and 2) reported its efficacy in treating heavy menstrual bleeding related to myomas with a good safety profile. Further studies will determine the necessity of add-back therapy during long-term use of linzagolix.

Risk factors for ovarian endometrioma recurrence following surgical excision: a systematic review and meta‑analysis

PURPOSE

Exploring potential risk factors for OMA recurrence, thereby contributing to the individual management of the disease and improving the patients' prognosis.

METHODS

Data sources PubMed, Embase, the Cochrane Library, CNKI, and Wanfang data were searched systematically before October 2020. We computed the pooled odd ratios or the standard mean difference with their corresponding 95% confidence interval to investigate the impact of involved risk factors on endometrioma recurrence.

RESULTS

The pooled findings of this meta-analysis demonstrated that endometrioma relapse was closely related to age at surgery [SMD (95% CI):  - 0.28 (- - 0.38 to  - 0.17), P < 0.00001], CA125 level [SMD (95% CI): 0.51 (0.14-0.88), P = 0.007], cyst size [SMD (95% CI): 0.35 (0.08-0.62), P = 0.01], dysmenorrhea [OR (95% CI): 1.47 (1.07-2.02), P = 0.02], endometriosis-related surgery history [OR (95% CI): 2.60 (1.84-3.67), P < 0.00001], pre-operative medication [OR (95% CI): 2.13 (1.41-3.22), P = 0.0003], rASRM score [SMD (95% CI): 0.33 (0.20-0.46), P < 0.00001]. Furthermore, post-operative pregnancy was indicated a protective factor for preventing the OMA recurrence after surgery [OR (95% CI): 0.22 (0.09-0.56), P = 0.001] CONCLUSION: Age at surgery, CA125 level, cyst size, dysmenorrhea, endometriosis-related surgery history, pre-operative medication, rASRM score were risk factors for endometrioma relapse. In addition, post-operative pregnancy was a protective factor for preventing recurrence after surgery. However, the effect of bilateral involvement, combination with adenomyosis, or post-operative medication on endometrioma relapse need further investigations.

Diagnosis and Treatment of Endometriosis. Guideline of the DGGG, SGGG and OEGGG (S2k Level, AWMF Registry Number 015/045, August 2020)

Aims The aim of this official guideline published and coordinated by the German Society of Gynaecology and Obstetrics (DGGG) in cooperation with the Austrian Society for Gynaecology and Obstetrics (OEGGG) and the Swiss Society for Gynaecology and Obstetrics (SGGG) was to provide consensus-based recommendations for the diagnosis and treatment of endometriosis based on an evaluation of the relevant literature. Methods This S2k guideline represents the structured consensus of a representative panel of experts with different professional backgrounds commissioned by the Guideline Committee of the DGGG, OEGGG and SGGG. Recommendations Recommendations on the epidemiology, aetiology, classification, symptomatology, diagnosis and treatment of endometriosis are given and special situations are discussed.

GnRH-a-Induced Perimenopausal Rat Modeling and Black Cohosh Preparations' Effect on Rat's Reproductive Endocrine

BACKGROUND

Endometriosis (EMS) is an estrogen-dependent disease, which easily recurs after operation. Gonadotropin-releasing hormone agonist (GnRH-a), an estrogen-inhibiting drug, can effectively inhibit the secretion of gonadotropin by pituitary gland, so as to significantly decrease the ovarian hormone level and facilitate the atrophy of ectopic endometrium, playing a positive role in preventing postoperative recurrence. The application of GnRH-a can lead to the secondary low estrogen symptoms, namely the perimenopausal symptoms, and is a main reason for patients to give up further treatment. The add-back therapy based on sex hormones can well address the perimenopausal symptoms, but long-term use of hormones may cause the recurrence of EMS, as well as liver function damage, venous embolism, breast cancer and other risks, which has long been a heated topic in the industry. Therefore, it is necessary to find effective and safe anti-additive drugs soon. Studies at home and abroad show that, as a plant extract, isopropanolic extract of cimicifuga racemosa (ICR) can well relieve the perimenopausal symptoms caused by natural menopause. Some studies have preliminarily confirmed that black cohosh preparations can antagonize perimenopausal symptoms of EMS patients treated with GnRH-a after operation.

OBJECTIVE

To establish a rat model of perimenopausal symptoms induced by GnRH-a injection, for the purposes of laying a foundation for further research and preliminarily exploring the effect of black cohosh preparations on reproductive endocrine of the rat model.

METHOD

The rat model of perimenopausal symptoms was established by GnRH-a injection, and normal saline (NS injection) was used as the control. The rats were randomly divided into four groups according to different modeling methods and drug intervention schemes. GnRH-a injection + normal saline intervention group (GnRH-a + NS), normal saline injection control + normal saline intervention group (NS + NS), GnRH-a injection + estradiol intervention group (GnRH-a + E2), and GnRH-a injection + black cohosh preparations intervention group (GnRH-a + ICR). After modelling was assessed to be successful with the vaginal smear method, the corresponding drugs were given for intervention for 28d. In the process of rat modeling and drug intervention, the skin temperature and anus temperature of the rat tails were measured every other day, the body weights of the rats were measured every other day, and the dosage was adjusted according to the body weight. After the intervention was over, the serum sex hormone level, the uterine weight, the uterine index, and the endometrial histomorphology changes, as well as the ovarian weight, the ovarian index, and the morphological changes of ovarian tissues of each group were measured.

RESULTS

(1) The vaginal cell smears of the control group (NS + NS) showed estrous cycle changes, while other model rats had no estrous cycle of vaginal cells. (2) The body weight gains of the GnRH-a + NS, GnRH-a + E2 and GnRH-a + ICR groups were significantly higher than that of the NS + NS control group. The intervention with E2 and ICR could delay the weight gain trend of rats induced by GnRH-A. (3) After GnRH-a injection, the temperature of the tail and anus of rats showed an overall upward trend, and the intervention with E2 and ICR could effectively improve such temperature change. (4) The E2, FSH, and LH levels in the GnRH-a + NS, GnRH-a + E2, and GnRH-a + ICR groups were significantly lower than those in the NS + NS group (P < 0.01). The E2 level was significantly higher and the LH level was significantly lower in the GnRH-a + E2 group than those in the GnRH-a + NS and GnRH-a + ICR groups (P < 0.05). Compared with those of the GnRH-a + NS and GnRH-a + ICR groups, the FSH level of the GnRH-a + E2 group showed a slight downward trend, but the difference was not statistically significant (P > 0.05). There was no significant difference in the levels of sex hormones between the GnRH-a + NS group and GnRH-a + ICR group (P > 0.05). (5) Compared with those of the NS + NS group, the uterine weight and uterine index of the GnRH-a + NS, GnRH-a + E2 and GnRH-a + ICR groups significantly decreased (P < 0.01). In a comparison between the groups, the uterine weight and uterine index in the GnRH-a + NS and GnRH-a + ICR groups were significantly lower than those in the GnRH-a + E2 group (P < 0.01). There was a statistical difference in the uterine weight and uterine index between the GnRH-a + NS group and GnRH-a + ICR group (P > 0.05). (6) Compared with those of the NS + NS group, the ovarian weight and ovarian index of the GnRH-a + NS, GnRH-a + E2 and GnRH-a + ICR groups significantly decreased (P < 0.01). There was no statistical difference in the ovarian weight and ovarian index among the GnRH-a + E2, GnRH-a + NS and GnRH-a + ICR groups (P > 0.05). (7) Compared with those in the NS + NS group, the number of primordial follicles increased significantly, while the number of growing follicles and mature follicles decreased significantly in the GnRH-a + NS, GnRH-a + E2, and GnRH-a + ICR groups (P < 0.01), but there was a statistical difference in the total number of follicles among the four groups (P > 0.05).

CONCLUSIONS

The GnRH-a injection could achieve the desired effect. The animal model successfully achieved a significant decrease in the E2, FSH, and LH levels in rats, and could cause the rats to have rising body surface temperature similar to hot flashes in the perimenopausal period. The intervention with E2 and ICR could effectively relieve such "perimenopausal symptoms", and ICR had no obvious effect on the serum sex hormone level in rats.

Characteristics and long-term outcomes of perineal endometriosis: A retrospective study

To summarize the clinical features, diagnosis, and treatments of perineal endometriosis (PEM).We retrospectively studied the clinical data of 35 patients with PEM between April 2012 and December 2018 in West China Second Hospital. Patients were divided into the gonadotropins releasing hormone (GnRH) agonist group and non-GnRH agonist group.The main clinical symptom was vulvar painful swellings related to menstrual cycles. Thirty-three patients' lesions (94.29%) were on the episiotomy scar while 1 case was at the opposite side of the scar. We even found 1 nullipara was diagnosed as PEM. Ten patients (28.57%) were found with anal sphincter involvement. All patients received complete excision of PEM. The recurrence rate of GnRH agonist group was 7.69% (1/13), while the rate of non-GnRH agonist group was 18.75% (3/16).Most PEM was associated with episiotomy history, but PEM could also exist in nullipara. Complete excision of PEM was inevitable. The effect of GnRH agonist on recurrence of PEM needs further studies.

Age at surgery and recurrence of ovarian endometrioma after conservative surgery: a meta-analysis including 3125 patients

PURPOSE

To evaluate the association between age at surgery and recurrence rate of endometrioma. Data sources PubMed, Embase, and the Cochrane Library were searched up to October 2019.

METHODS

We determined the pooled relative risk (RR) and 95% confidence intervals (CIs) to assess the relationship between age at surgery and the recurrence rate of endometrioma after surgery. Begg's funnel plot and Egger's linear regression was used to assess any publication bias.

RESULTS

A total of 3125 patients from 10 studies were finally enrolled in this meta-analysis. The recurrence rate decreased with increasing age (RR = 0.93, 95% CI = 0.91-0.95, P = 0.451). Subgroup analysis demonstrated that the pooled RR was 0.926 (95% CI 0.906-0.947, P < 0.001) for a cut-off < 35, and 0.886 (95% CI 0.775-1.040, P = 0.14) for a cut-off ≥ 35. Begg's funnel plot and Egger's linear regression test showed no evidence of publication bias.

CONCLUSION

This meta-analysis suggested that younger age might be a high-risk factor for the recurrence of ovarian endometrioma after conservative surgery.

A prospective, single-centre, single-arm, open label study of the long term use of a gonadotropin releasing hormone agonist (Triptorelin SR, 11.25 mg) in combination with Tibolone add-back therapy in the management of chronic cyclical pelvic pain

BACKGROUND

Chronic cyclic pelvic pain (CCPP) affects women's quality of life and pituitary downregulation is often used for symptomatic relief. However, prolonged suppression of ovarian function is associated with menopausal side effects and can lead to osteoporosis. Currently, the use of gonadotropin releasing hormone agonists (GnRHa) for treatment of CCPP is usually restricted to 6-9 months, limiting their efficacy. There is limited information regarding safety and efficacy with longer-term use. The aim of this study is to examine the safety and efficacy of long-term (24 months) pituitary down-regulation with the GnRHa (Triptorelin SR) with add-back therapy (ABT) using Tibolone for symptom relief in women with CCPP.

METHODS

A single-arm, prospective clinical trial at a Tertiary University Teaching Hospital of 27 patients receiving Triptorelin SR (11.25 mg) and Tibolone (2.5 mg). Outcomes measures were the safety of treatment assessed by clinical examination, haematological markers, liver and renal function tests and bone mineral density (BMD) at 12, 18 and 24 months as well as at 6 months post-treatment. Pain and health-related quality of life (HR-QoL) assessed using the endometriosis health profile (EHP-30) and chronic pain grade (CPG) questionnaires.

RESULTS

There was no evidence for any significant harmful effects on any of the measured haematological, renal or liver function tests. Although results regarding the effect on BMD are not conclusive there is an increased risk of development of osteopaenia after 12 months of treatment. Pain and HRQoL assessments showed significant improvement during medication, but with deterioration after treatment cessation.

CONCLUSION

Long- term Triptorelin plus Tibolone add-back therapy in women suffering from CCPP does not appear to be associated with significant serious adverse events apart from the possibility of deterioration in the BMD that needs to be monitored. This mode of therapy appears to be effective in pain relief and in improving quality of life over a 24-month period.

TRIAL REGISTRATION

Clinical trials database NCT00735852.

Malignant risk of pelvic mass after hysterectomy for adenomyosis or endometriosis

Pelvic mass onset following a hysterectomy due to benign disease is not rarely seen. Appropriate diagnosis and treatment are of great importance.This study aims to analyze the clinicopathological features of patients who have received surgery for pelvic mass following hysterectomy due to gynecological benign disease, especially endometriosis or adenomyosis.This study retrospectively analyzed the patients undergone reoperation for pelvic mass subsequently to hysterectomy from January 2012 to December 2016 in a tertiary teaching hospital.A total of 247 patients were enrolled in this study. There is a significant difference between the patients with or without a history of endometriosis/adenomyosis. Multivariate analysis showed that the pelvic mass had a higher risk of being ovarian endometrioid carcinoma, ovarian clear cell carcinoma, ovarian endometriosis, and ovarian physiological cysts in patients with a history of adenomyosis/endometriosis.The pathology of the subsequent pelvic mass inclines to be benign, includes ovarian endometriosis, ovarian physiological cysts, and pelvic encapsulated effusion. Postoperative adjuvant therapy for those received hysterectomy due to endometriosis/adenomyosis, like gonadotropin releasing hormone agonists (GnRHa), may contribute to the prevention of benign pelvic mass. Patients with a history of hysterectomy due to endometrisos/adenomyosis tend to have a shorter time interval between hysterectomy and pelvic malignant tumors onset.

Surgical treatment of endometriosis: prognostic factors for better quality of life

The present study investigated the effect of surgical treatment of endometriosis on physical and mental health. We undertook a prospective survey including 153 premenopausal women with histological diagnosis of endometriosis. The Short Form 12 (SF-12) questionnaire comprising physical and mental component scales was used. Two groups of patients were distinguished: Group A (n = 42) with SF-12 scores above the median in both physical and mental scales; Group B (n = 111) with SF-12 scores below the median in either physical or mental scale. Group A was diagnosed and operated for endometriosis for the first time at an older age (30 vs. 26 years), had undergone more frequently a single surgical intervention (64% vs. 46%), was less affected by symptom or lesion recurrence and had reported less intense current pain symptoms than Group B. Having the first endometriosis surgery at a later age was an independent predictor of better health status (adjusted odds ratio 1.146 per year, 95% confidence interval 1.058-1.242) after accounting for the potential confounding effects of reoperation, pelvic pain and time elapsed since the first surgery. In conclusion, patients with endometriosis who had a single surgery at an older age have good symptom control and better quality of life (QoL).

Comparison of Outcomes of Different Postoperative Hormone Therapy in the Treatment of Ovarian Endometriosis: A Brief Report

INTRODUCTION

Hormone therapy is widely used in the treatment of patients with ovarian endometriosis after surgery, and progestin and gonadotropin-releasing hormone (GnRH) are two of the most widely used hormones. This study aimed to compare the outcomes of progestin and GnRH in the treatment of ovarian endometriosis after surgery.

METHODS

A total of 399 patients with ovarian endometriosis were included and divided into four groups to receive different treatments. Group A received no postoperative hormone therapy; patients in group B1 and B2 were treated with different doses of norethindrone (progestin, 1.2 and 5 mg/day, respectively); patients in group C were treated with GnRH (2.0 mg every 2 weeks). Treatment outcomes including menstrual bleeding profiles, cumulative recurrence rate, incidence of complications, and endometrioma diameter in the case of recurrence were recorded and compared between groups.

RESULTS

Compared with group A, group B1, B2 and C showed significantly improved menstrual bleeding profiles and reduced cumulative recurrence rate and endometrioma diameter after recurrence. In addition, compared with group C, menstrual bleeding profiles were significantly improved and cumulative recurrence rate and endometrioma diameter were significantly reduced in group B1 and B2. No significant differences in incidence of complications during treatment were found among groups. After treatment, recurrence rate and endometrioma diameter were significantly increased in group B1, B2, and C.

CONCLUSION

Both progestin and GnRH can significantly improve the conditions of patients with ovarian endometriosis after surgery, but progestin may be a better choice. Both therapies are challenged by the increased recurrence rate and endometrioma diameter after treatment.

Medical therapy for preventing recurrent endometriosis after conservative surgery: a cost-effectiveness analysis

OBJECTIVE

To assess the cost-effectiveness of different strategies, including gonadotropin-releasing hormone agonist (GnRH-a) and oral contraceptive therapy, for the prevention of endometriosis recurrence after conservative surgery.

DESIGN

Cost-effectiveness analysis from a health care perspective.

SETTING

A health-resource-limited setting in China.

POPULATION

Patients who underwent conservative laparoscopic or laparotomic surgery for endometriosis.

METHODS

A Markov model was developed for the endometriosis disease course. Clinical data were obtained from published studies. Direct medical costs and resource utilization in the Chinese health care setting were taken into account. The health and economic outcomes were evaluated over a period from treatment initiation to menopause onset. Sensitivity analyses were carried out to test the impact of various parameters and assumptions on the model output.

MAIN OUTCOME MEASURES

Quality-adjusted life years (QALYs) gained and costs from a health care perspective.

RESULTS

The incremental cost-effectiveness ratio of 6-month GnRH-a therapy compared with no therapy ranged from $6,185 per QALY in deep endometriosis to $6,425 with peritoneal endometriosis. A one-way sensitivity analysis showed considerable influential factors, such as remission rates and utility values. Probabilistic sensitivity analysis indicated that 6-month GnRH-a therapy is cost-effective in most cases at a threshold of $7,400/QALY, regardless of the type of endometriosis.

CONCLUSION

Six months of therapy with GnRH-a can be a highly cost-effective option for the prevention of endometriosis recurrence.

TWEETABLE ABSTRACT

Gonadotropin-releasing hormone agonist is cost effective for the prevention of endometriosis recurrence.

Research development of a new GnRH antagonist (Elagolix) for the treatment of endometriosis: a review of the literature

PURPOSE

Limitated studies have reported the efficacy of GnRH antagonist on endometriosis symptoms. The aim of our study was to review all available trials to investigate the medical treatment of endometriosis with only GnRH antagonists, with special attention to pharmacodynamic activity, safety, and efficacy.

METHODS

Pub Med and Sciencedirect database were searched using terms of "endometriosis treatment", "GnRH antagonist", and "Elagolix". The search was limited to clinical studies published in English. Title and abstract were screened to identify relevant articles.

RESULTS

Five studies covering use of GnRH antagonist were found. A phase 1 study evaluated the safety, pharmacokinetics, and inhibitory effects on gonadotropins and estradiol of single dose and 7 day elagolix administration to healthy premenopausal women; two phase II studies evaluated efficacy in patient with endometriosis. Moreover, there are two Phase III clinical trials just completed.

CONCLUSION

GnRH antagonists may have the advantage of oral administration and lower incidence of adverse events. Currently, only Phase II studies have been published demonstrating promising results in terms of efficacy, safety, and tolerability. From the results of the phase III studies, elagolix may become a valuable addition to the armamentarium of pharmacological agents to treat endometriosis-related pain.

Pharmacologic treatment of the ovarian endometrioma

INTRODUCTION

Treatment of ovarian endometriomas is commonly achieved through laparoscopic surgery and this can be effective in eliminating the disease, although a majority of recent trials documented an adverse effect of surgery on ovarian reserve markers. With the advancement in imaging techniques, ovarian endometriomas are increasingly diagnosed at an earlier stage when the endometrioma may be smaller, less fibrotic and more responsive to medical treatment, making an evaluation of medical options critically important.

AREAS COVERED

The review focuses on currently utilized pharmacologic therapies for endometrioma (oral contraceptives, the levonorgestrel-releasing IUS, the hormone-releasing subdermal implant, Implanon); experimental and future treatments are also mentioned (GnRH antagonists, progesterone receptor modulators, antioestrogens, newer subdermal implants and intracystic administration of pharmacologic agents). Finally, the usefulness of post-operative adjuvant medical treatments is discussed Expert opinion: Today, reliable, non-invasive diagnostic procedures of an ovarian endometrioma are available and should be utilized to identify its presence and type of pathology. In a young patient, classic medical therapies such as oral contraceptives and synthetic progestins should be tried first to alleviate symptoms. Only when these regimens fail, should a minimally invasive surgery be envisaged. Following endoscopic surgery, adjuvant medical treatment may reduce recurrence of both symptoms and the lesion.