Recurrence rate of endometrioma after laparoscopic cystectomy: A comparative randomized trial between post-operative hormonal suppression treatment or dietary therapy vs. placebo

Efficacy and safety of different subsequent therapies after fertility preserving surgery for endometriosis: A systematic review and network meta-analysis

BACKGROUND

Endometriosis (EMT) is a benign and common estrogen-dependent disease. Hormonal therapy improves pain symptoms in most women with EMT. However, in many cases, laparoscopic fertility preservation surgery is considered a common treatment for EMT. The present study aimed to evaluate the efficacy and safety of dienogest, leuprolide, danazol, gestrinone, mifepristone and levonorgestrel intrauterine system (LNG-IUS) in relieving symptoms and delaying the recurrence of EMT cysts after fertility protection surgery.

METHODS

We searched PubMed, the Cochrane Library, Web of Science, EMBase, China National Knowledge Infrastructure, VIP Database, China Biology Medicine disc, WanFang Data databases to collect randomized controlled trials (RCT) related to dienogest, leuprolide, danazol, gestrinone, mifepristone and LNG-IUS as a follow-up treatment after fertility preserving surgery for EMT. After literature screening, data extraction and quality evaluation, effective rate, recurrence rate, pregnancy rate and adverse reaction rate were used as outcome indicators to evaluate the efficacy and safety of drugs. Evidence networks included in the study were drawn and publication bias was assessed. The drugs most likely to be the best postoperative treatment were explored through mixed comparison of different drugs and efficacy ranking.

RESULT

Effective rate: dienogest, leprerelin, gestrinone and LNG-IUS were better than placebo after EMT fertility preservation surgery; dienogest was superior to mifepristone and danazol. LNG-IUS is superior to danazol. LNG-IUS has the highest potential for improving the effectiveness of EMT symptoms. Recurrence rate: the application of dienogest, leuprolide, gestrinone, mifepristone and LNG-IUS after EMT fertility preservation surgery was lower than that of placebo; dienogest and LNG-IUS were lower than danazol. The recurrence rate of dinorgestrel was the last place with the highest performance. Pregnancy rate: in the cases with fertility requirements, dienogest and,leuprolide were better than placebo after EMT fertility preservation surgery; dienogest was superior to danazol, gestrinone and mifepristone. Leuprolide is superior to danazol and gestrinone. The first rank of dienogest pregnancy rate was the highest. Adverse reaction rate: the application of dienogest, leuprolide, danazol, gestrinone, mifepristone and LNG-IUS after EMT fertility preservation surgery was higher than that of placebo. After placebo, LNG-IUS had the highest adverse reaction rate.

CONCLUSION

For patients after fertility preserving surgery for EMT, the recurrence rate of dienogest was the last place with highest preference. The first rank of dienogest pregnancy was the highest.

The relationship between endometriosis and diet

Endometriosis is an oestrogen dependent, benign, chronic inflammatory disease characterised by ectopic endometrial implants. Current medical practices for the treatment of the disease are associated with several side effects over long periods, making the effect of diet on endometriosis an important aspect. To alleviate this need, we review related literature to identify the association between nutrients and endometriosis and to find the probable therapeutic effects of the nutrients and foods on endometriosis. Despite variations among the findings, several of the prior studies point to an inverse relationship between endometriosis and the consumption of fruits, vegetables, dairy products, and omega-3 fatty acids. Another common finding among the studies is the increased risk of endometriosis with higher consumption of trans-unsaturated fatty acids and red meat. Due to the limited size of the samples in existing literature, however, significance of the association between diet and endometriosis is not conclusive. Further research is needed to better identify the role of diet on endometriosis.

Comparing the effect of adjunctive N-acetylcysteine plus low dose contraceptive with low dose contraceptive alone on recurrence of ovarian endometrioma and chronic pelvic pain after conservative laparoscopic surgery: a randomised clinical trial study

This study aimed to compare the effectiveness of NAC plus low dose contraceptive with low dose contraceptives alone. This was a randomised trial on a sample of women who underwent conservative laparoscopic surgery for ovarian endometrioma. Patients were randomly assigned either to the NAC plus low dose contraceptive group (n = 48) or low dose contraceptive alone (n = 52). To evaluate the recurrence rate transvaginal ultrasound was performed. Pelvic pain was assessed using a visual analogue scale (VAS). All assessments were performed at two points in time: 3 and 6 months post-surgery and compared between the two regimens. The findings indicated that reduction in the recurrence rate of endometrioma and pelvic pain were similar between both groups. The findings showed that adding N-acetylcysteine to low dose contraceptive treatment has a similar effect in reducing the recurrence rate of endometrioma and pelvic pain when compared to low dose contraceptives alone.Impact statementWhat is already known on this subject? Endometriosis is a frequent benign disease-producing inflammatory response with mild to severe symptoms. Although surgical removal of ectopic lesions is the first-line intervention, the recurrence rate of the disease is high. Thus this study aimed to compare the effectiveness of N-acetylcysteine plus low dose contraceptive with low dose contraceptive alone.What do the results of this study add? The findings showed that adding N-acetylcysteine to low dose contraceptive treatment has a similar effect in reducing the recurrence rate of endometrioma and pelvic pain when compared to low dose contraceptives alone.What are the implications of these findings for clinical practice and/or further research? It is recommended to increase the duration of drug administration in future studies.

Long-term follow-up of endometriosis surgery in Ontario: a population-based cohort study

BACKGROUND

Endometriosis is a chronic gynecological disease affecting approximately 10% of reproductive aged females and leads to decreased quality of life and productivity. Despite effective medical options, many women do require surgery for endometriosis. There is limited literature examining long term outcomes of endometriosis surgery.

OBJECTIVE

This study aimed to characterize the long-term outcomes, including recurrence of symptoms, fertility outcomes, and need for reoperation, of patients who underwent surgical management for endometriosis.

STUDY DESIGN

This was a population-based cohort study in which the universal coverage health database for the province of Ontario, Canada, was used to identify women aged 18 to 50 years who underwent surgery for endometriosis from April 1, 2002, through March 31, 2018. Surgery was classified as diagnostic laparoscopy, conservative or uterine preserving (minor or major, with and without ovarian preservation), or hysterectomy (with and without ovarian preservation). The outcomes were evaluated from 30 days after the index surgery to the end of the study period or at censoring. Cox proportional hazard regression models were used to estimate the hazard ratios between exposures and outcomes following adjustment for confounders.

RESULTS

A total of 84,885 women 2,718 (3.2%) diagnostic laparoscopy, 21,594 (25.4%) minor conservative surgery, 28,484 (33.6%); major conservative with ovarian preservation, 2,102 (2.5%) major conservative without ovarian preservation, 21,609 (25.5%) hysterectomy with ovarian preservation, and 8,378 (9.9%) hysterectomy without ovarian preservation) were included in the cohort and followed for a median of 10 years (interquartile range, 6-13 years). In the first postoperative year, women who underwent diagnostic laparoscopy were significantly more likely to require repeat surgery (adjusted hazard ratio, 1.68; 95% confidence interval, 1.51-1.87), whereas those who underwent major conservative surgery were significantly less likely to require repeat surgery (with ovarian preservation: adjusted hazard ratio, 0.44; 95% confidence interval, 0.41-0.48; without ovarian preservation: adjusted hazard ratio, 0.05; 95% confidence interval, 0.03-0.09). Among women who did not receive repeat surgery in the first year, those who underwent a diagnostic laparoscopy (adjusted hazard ratio, 0.85; 95% confidence interval, 0.76-0.95) and major conservative surgery without ovarian preservation were less likely to undergo repeat surgery (adjusted hazard ratio, 0.12; 95% confidence interval, 0.09-0.18) than those who initially had minor surgery. Compared with those who initially underwent minor surgery, patients who underwent other treatment modalities were less likely to undergo a hysterectomy (diagnostic laparoscopy: adjusted hazard ratio, 0.85; 95% confidence interval, 0.75-0.96; major surgery with ovarian preservation: adjusted hazard ratio, 0.60; 95% confidence interval, 0.57-0.64; major surgery without ovarian preservation: adjusted hazard ratio, 0.05; 95% confidence interval, 0.03-0.08). Following minor and major conservative with ovarian preservation surgery, 8,331 (38.6%) and 9,498 (33.3%) of patients sought an infertility consult within 1 year, respectively. By 5 years after the index surgery, 5,290 (29.4%) of patients who had minor conservative surgery and 4,528 (20.7%) of those who had major conservative with ovarian preservation surgery had given birth at least once.

CONCLUSION

Our study suggests that only a few endometriosis patients who undergo hysterectomy surgery require repeat surgery; however, up to 1 in 4 who undergo minor surgery and 1 in 5 who undergo major conservative surgery with ovarian preservation require additional endometriosis surgery. Up to 1 in 3 patients who had uterine sparing endometriosis surgery subsequently sought an infertility assessment. These findings may inform preoperative counseling in terms of recurrence of symptoms, fertility outcomes, and need for reoperation of women seeking surgical management for endometriosis. Future studies should consider the outcomes of patient satisfaction and quality of life based on the current practices for management of endometriosis.

Postoperative hormonal treatment for prevention of endometrioma recurrence after ovarian cystectomy: a systematic review and network meta-analysis

BACKGROUND

The efficacy of hormonal regimens for the prevention of endometrioma recurrence in women who have undergone conservative surgery is still controversial.

OBJECTIVE

To compare the efficacy of different hormonal regimens in this context and to rank them.

SEARCH STRATEGY

MEDLINE and Scopus databases were searched through January 2020.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or cohorts, comparing the effect of any pair of interventions (i.e. cyclic oral contraceptives [OC], continuous OC, gonadotropin-releasing hormone agonist [GnRHa], dienogest [DNG], levonorgestrel-releasing intrauterine system [LNG-IUS] and expectant management) on endometrioma recurrence were selected.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by two reviewers. Relative treatment effects were estimated using network meta-analysis (NMA) and ranked in descending order.

MAIN RESULTS

Six RCTs (675 patients) and 16 cohorts (3089 patients) were included. NMA of the RCTs involving expectant management, cyclic OC, continuous OC, GnRHa and GnRHa + LNG-IUS, showed that all hormonal regimens had a nonsignificant lower risk of endometrioma recurrence compared with expectant management. NMA of the cohorts involving expectant, cyclic OC, continuous OC, GnRHa, DNG, LNG-IUS, GnRHa + OC, and GnRHa + LNG-IUS indicated that LNG-IUS, DNG, continuous OC, GnRHa + OC and cyclic OC had a significantly lower risk of endometrioma recurrence than expectant management. LNG-IUS was ranked highest, followed by DNG and GnRHa + LNG-IUS. Long-term use of hormonal treatment either OC or progestin had a significantly lower risk of endometrioma recurrence than expectant treatment.

CONCLUSION

In the NMA of RCTs, there was no evidence supporting hormonal treatment for postoperative prevention of endometrioma recurrence. This was at odds with the cohort evidence, which found the protective effect of OC and progestin regimens, especially long-term treatment. Large-scale RCTs of these agents are still required.

TWEETABLE ABSTRACT

Hormonal regimens given as long-term treatment tend to reduce risk of endometrioma recurrence after conservative surgery.

Pre- and postsurgical medical therapy for endometriosis surgery

BACKGROUND

Endometriosis is a common gynaecological condition affecting 10% to 15% of reproductive-age women and may cause dyspareunia, dysmenorrhoea, and infertility. One treatment strategy is combining surgery and medical therapy to reduce the recurrence of endometriosis. Though the combination of surgery and medical therapy appears to be beneficial, there is a lack of clarity about the appropriate timing of when medical therapy should be used in relation with surgery, that is, before, after, or both before and after surgery, to maximize treatment response.

OBJECTIVES

To determine the effectiveness of medical therapies for hormonal suppression before, after, or both before and after surgery for endometriosis for improving painful symptoms, reducing disease recurrence, and increasing pregnancy rates.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, and two trials registers in November 2019 together with reference checking and contact with study authors and experts in the field to identify additional studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) which compared medical therapies for hormonal suppression before, after, or before and after, therapeutic surgery for endometriosis.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. Where possible, we combined data using risk ratio (RR), standardized mean difference or mean difference (MD) and 95% confidence intervals (CI). Primary outcomes were: painful symptoms of endometriosis as measured by a visual analogue scale (VAS) of pain, other validated scales or dichotomous outcomes; and recurrence of disease as evidenced by EEC (Endoscopic Endometriosis Classification), rAFS (revised American Fertility Society), or rASRM (revised American Society for Reproductive Medicine) scores at second-look laparoscopy.

MAIN RESULTS

We included 26 trials with 3457 women with endometriosis. We used the term "surgery alone" to refer to placebo or no medical therapy. Presurgical medical therapy compared with placebo or no medical therapy Compared to surgery alone, we are uncertain if presurgical medical hormonal suppression reduces pain recurrence at 12 months or less (dichotomous) (RR 1.10, 95% CI 0.72 to 1.66; 1 RCT, n = 262; very low-quality evidence) or whether it reduces disease recurrence at 12 months - total (AFS score) (MD -9.6, 95% CI -11.42 to -7.78; 1 RCT, n = 80; very low-quality evidence). We are uncertain if presurgical medical hormonal suppression decreases disease recurrence at 12 months or less (EEC stage) compared to surgery alone (RR 0.88, 95% CI 0.78 to 1.00; 1 RCT, n = 262; very low-quality evidence). We are uncertain if presurgical medical hormonal suppression improves pregnancy rates compared to surgery alone (RR 1.16, 95% CI 0.99 to 1.36; 1 RCT, n = 262; very low-quality evidence). No trials reported pelvic pain at 12 months or less (continuous) or disease recurrence at 12 months or less. Postsurgical medical therapy compared with placebo or no medical therapy We are uncertain about the improvement observed in pelvic pain at 12 months or less (continuous) between postsurgical medical hormonal suppression and surgery alone (MD -0.48, 95% CI -0.64 to -0.31; 4 RCTs, n = 419; I² = 94%; very low-quality evidence). We are uncertain if there is a difference in pain recurrence at 12 months or less (dichotomous) between postsurgical medical hormonal suppression and surgery alone (RR 0.85, 95% CI 0.65 to 1.12; 5 RCTs, n = 634; I² = 20%; low-quality evidence). We are uncertain if postsurgical medical hormonal suppression improves disease recurrence at 12 months - total (AFS score) compared to surgery alone (MD -2.29, 95% CI -4.01 to -0.57; 1 RCT, n = 51; very low-quality evidence). Disease recurrence at 12 months or less may be reduced with postsurgical medical hormonal suppression compared to surgery alone (RR 0.30, 95% CI 0.17 to 0.54; 4 RCTs, n = 433; I² = 58%; low-quality evidence). We are uncertain about the reduction observed in disease recurrence at 12 months or less (EEC stage) between postsurgical medical hormonal suppression and surgery alone (RR 0.80, 95% CI 0.70 to 0.91; 1 RCT, n = 285; very low-quality evidence). Pregnancy rate is probably increased with postsurgical medical hormonal suppression compared to surgery alone (RR 1.22, 95% CI 1.06 to 1.39; 11 RCTs, n = 932; I² = 24%; moderate-quality evidence). Pre- and postsurgical medical therapy compared with surgery alone or surgery and placebo There were no trials identified in the search for this comparison. Presurgical medical therapy compared with postsurgical medical therapy We are uncertain about the difference in pain recurrence at 12 months or less (dichotomous) between postsurgical and presurgical medical hormonal suppression therapy (RR 1.40, 95% CI 0.95 to 2.07; 2 RCTs, n = 326; I² = 2%; low-quality evidence). We are uncertain about the difference in disease recurrence at 12 months or less (EEC stage) between postsurgical and presurgical medical hormonal suppression therapy (RR 1.10, 95% CI 0.95 to 1.28; 1 RCT, n = 273; very low-quality evidence). We are uncertain about the difference in pregnancy rate between postsurgical and presurgical medical hormonal suppression therapy (RR 1.05, 95% CI 0.91 to 1.21; 1 RCT, n = 273; very low-quality evidence). No trials reported pelvic pain at 12 months or less (continuous), disease recurrence at 12 months - total (AFS score) or disease recurrence at 12 months or less (dichotomous). Postsurgical medical therapy compared with pre- and postsurgical medical therapy There were no trials identified in the search for this comparison. Serious adverse effects for medical therapies reviewed There was insufficient evidence to reach a conclusion regarding serious adverse effects, as no studies reported data suitable for analysis.

AUTHORS' CONCLUSIONS

Our results indicate that the data about the efficacy of medical therapy for endometriosis are inconclusive, related to the timing of hormonal suppression therapy relative to surgery for endometriosis. In our various comparisons of the timing of hormonal suppression therapy, women who receive postsurgical medical therapy compared with no medical therapy or placebo may experience benefit in terms of disease recurrence and pregnancy. There is insufficient evidence regarding hormonal suppression therapy at other time points in relation to surgery for women with endometriosis.

Endometriosis recurrence following post-operative hormonal suppression: a systematic review and meta-analysis

BACKGROUND

Although surgery for endometriosis can improve pain and fertility, the risk of disease recurrence is high. There is little consensus regarding the benefit of medical therapy in preventing recurrence of endometriosis following surgery.

OBJECTIVE AND RATIONALE

We performed a review of prospective observational studies and randomised controlled trials (RCTs) to evaluate the risk of endometriosis recurrence in patients undergoing post-operative hormonal suppression, compared to placebo/expectant management.

SEARCH METHODS

The following databases were searched from inception to March 2020 for RCTs and prospective observational cohort studies: MEDLINE, Embase, Cochrane CENTRAL and Web of Science. We included English language full-text articles of pre-menopausal women undergoing conservative surgery (conserving at least one ovary) and initiating hormonal suppression within 6 weeks post-operatively with either combined hormonal contraceptives (CHC), progestins, androgens, levonorgesterel-releasing intra-uterine system (LNG-IUS) or GnRH agonist or antagonist. We excluded from the final analysis studies with <12 months of follow-up, interventions of diagnostic laparoscopy, experimental/non-hormonal treatments or combined hormonal therapy. Risk of bias was assessed using the Cochrane Risk of Bias Tool for RCTs and the Newcastle-Ottawa Scale (NOS) for observational studies.

OUTCOMES

We included 17 studies (13 RCTs and 4 cohort studies), with 2137 patients (1189 receiving post-operative suppression and 948 controls), which evaluated various agents: CHC (6 studies, n = 869), progestin (3 studies, n = 183), LNG-IUS (2 studies, n = 94) and GnRH agonist (9 studies, n = 1237). The primary outcome was post-operative endometriosis recurrence, determined by imaging or recurrence of symptoms, at least 12 months post-operatively. The secondary outcome was change in endometriosis-related pain. Mean follow up of included studies ranged from 12 to 36 months, and outcomes were assessed at a median of 18 months. There was a significantly decreased risk of endometriosis recurrence in patients receiving post-operative hormonal suppression compared to expectant management/placebo (relative risk (RR) 0.41, 95% CI: 0.26 to 0.65), 14 studies, 1766 patients, I² = 68%, random effects model). Subgroup analysis on patients treated with CHC and LNG-IUS as well as sensitivity analyses limited to RCTs and high-quality studies showed a consistent decreased risk of endometriosis recurrence. Additionally, the patients receiving post-operative hormonal suppression had significantly lower pain scores compared to controls (SMD −0.49, 95% CI: −0.91 to −0.07, 7 studies, 652 patients, I² = 68%).

WIDER IMPLICATIONS

Hormonal suppression should be considered for patients not seeking pregnancy immediately after endometriosis surgery in order to reduce disease recurrence and pain. Various hormonal agents have been shown to be effective, and the exact treatment choice should be individualised according to each woman’s needs.

Which is worse? Comparison of ART outcome between women with primary or recurrent endometriomas

STUDY QUESTİON

Are live birth rates (LBR) different after ART cycles between women with primary or recurrent endometrioma?

SUMMARY ANSWER

Women with recurrent endometrioma have similar LBR as compared to patients with primary endometrioma.

WHAT IS ALREADY KNOWN

Recurrence rate can be as high as 29% after endometrioma excision. Prior studies on management of endometrioma before ART involve primary endometriomas. There is limited information regarding the prognosis of women with recurrent endometriomas.

STUDY DESIGN, SIZE, DURATION

A multicenter retrospective cohort study, including 76 women with primary and 82 women with recurrent endometriomas treated at the participating centers over a 6-year period.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women with endometrioma who underwent ART at three academic ART centers. Couples with another indication for ART were excluded.

MAIN RESULTS AND THE ROLE OF CHANCE

Female age, median number of prior failed ART cycles, proportion of patients with bilateral endometrioma (28 versus 28.9%), ovarian stimulation protocols, and total gonadotropin consumption were similar between the study groups. Numbers of metaphase two oocytes (5 versus 6), number of embryos transferred, and the proportion of patients undergoing blastocyst transfer were similar across the study groups. Clinical pregnancy rates (36.6 versus 34.2%, absolute difference 2.4%, 95% CI: -12.5 to 17.3%, P = 0.83) and LBR (35.4 versus 30.3%, absolute difference 5.1%, 95% CI: -9.5 to 19.7%, P = 0.51) per started cycle in recurrent and primary endometrioma were similar. Comparable success rates were also confirmed with logistic regression analysis (OR: 1.14, 95% CI: 0.78-0.57, P = 2.3).

LIMITATIONS, REASONS FOR CAUTION

The retrospective design has inherent limitations. Some women with severely decreased ovarian reserve after primary endometrioma excision may not have pursued further treatment.

WIDER IMPLICATIONS OF THE FINDINGS

The management of endometrioma prior to ART is controversial but a different management strategy is not required for recurrent endometriomas. Since recurrent endometriomas do not have a worse impact on ART outcome than primary endometriomas, and repeat surgery has a higher risk for complications, conservative management without surgery can be justified.

STUDY FUNDING/COMPETING INTEREST(S)

No funding or competing interests to declare.

TRIAL REGISTRATION NUMBER

None.

Endometriosis and food habits: Can diet make the difference?

Endometriosis is a chronic, inflammatory, estrogenic-dependent disease characterized by the presence of endometrial glands outside the uterine cavity, affecting approximately 2%–10% of women in reproductive age and 30%–50% of women in general. Despite the high prevalence of the disease, not much is known about etiology, possible risk factors, and an adequate and satisfactory therapy. In the past years, many studies have focused on food intake (nutrients and food groups) and on its possible correlation with endometriosis, demonstrating how diet could be identified as a possible risk factor. Comprehensive searches in the largest medical information databases (Medline-PubMed, Embase, Lilacs, and Cochrane Library) were conducted using the Medical Subject Heading terms “diet,” “food,” “nutrition,” “fatty acids,” vitamins,” “fruit,” “vegetables,” “coffee,” “caffeine,” “fish,” “soy food,” “dairy products,” “tea,” “curcumin” combined with “endometriosis.” Purpose of this review is to revise the literature, in order to determine potential modifiable risk factors of the disease.

Endometriosis surgery and preservation of fertility, what surgeons should know

Colorectal surgeons often participate in the multidisciplinary management of young females with endometriosis. Complications of endometriosis as well as its management often result in infertility since they can involve all pelvic organs including the procreative organs: uterus, ovaries and fallopian tubes. Complete excision of all endometriotic lesions should not be performed at the expense of irreversible destruction of the procreative organs; definitive infertility should not be the price to pay in order to obtain an improvement of the painful symptoms caused by endometriosis. Surgery for ovarian endometriomas should be specifically adapted to the patient's desire for future conception and to her preoperative ovarian reserve. Two main techniques are used to treat ovarian endometriomas: ovarian cystectomy excises the wall of the cyst while ablation consists of destruction of the internal surface of the cyst. The use of mono polar or biolar coagulation for cyst ablation is strongly contra-indicated. Ablation using laser or plasma energy has resulted in comparable rates of post-operative pregnancy to those obtained by ovarian cystectomy. Patients who wish to delay their attempt to conceive for some period of time, should be placed on long-term oral contraception with prevention of menstruation to reduce the risk of recurrent endometriosis. When surgery for colorectal endometriosis is necessary, the laparoscopic approach increases the chances of spontaneous conception compared to laparotomy. Surgery for deep-seated endometriosis has been accompanied by a high rate of spontaneous conception and successful pregnancy and does not seem to decrease the chances for conception by in vitro fertilization.

[Endometriosis medical treatment: Hormonal treatment for the management of pain and endometriotic lesions recurrence. CNGOF-HAS Endometriosis Guidelines]

The available literature, from 2006 to 2017, on hormonal treatment has been analysed as a contribution to the HAS-CNGOF task force for the treatment of endometriosis. Available data are heterogeneous and the general level of evidence is moderate. Hormonal treatment is usually offered as the primary option to women suffering from endometriosis. It cannot be used in women willing to conceive. In women who have not been operated, the first line of hormonal treatment includes combined oral contraceptives (COC) and the levonorgestrel-releasing intra uterine system (52mg LNG-IUS). As a second line, desogestrel progestin only pills, etonogestrel implants, GnRH analogs (GnRHa) with add back therapy and dienogest can be offered. Add back therapy should include estrogens to prevent bone loss and improve quality of life, it can be introduced before the third month of treatment to prevent side effects. The literature does not support preoperative hormonal treatment for the sole purpose of reducing complications or recurrence, or facilitating surgical procedures. After surgical treatment, hormonal treatment is recommended to prevent pain recurrence and improve quality of life. COCs or LNG IUS are recommended as a first line. To prevent recurrence of endometriomas COC is advised and maintained as long as tolerance is good in the absence of pregnancy plans. In case of dysmenorrhea, postoperative COC should be used in a continuous scheme. GnRHa are not recommended in the sole purpose of reducing endometrioma recurrence risk.

[Medical treatment of endometriosis: Hormonal treatment of pain, impact on evolution and future perspectives]

CONTEXT

Endometriosis is a chronic painful disease, for which hormone therapy is usually offered as a first line option to women not willing to conceive.

OBJECTIVES

To analyse and synthesize the literature, from 2006 onwards, on pain control, and disease evolution in oemn using combined hormonal contraceptives, progestins and GnRH analogs. Data on other current and future treatment perspectives is included as well.

SOURCES

Medline (Pubmed), the Cochrane Library, and endometriosis treatment recommendations published by European Society of Human Reproduction and Embryology (ESHRE), National Institute for health and Care Excellence (NICE), American College of Obstetricians and Gynecologists (ACOG), Royal College of Obstetricians and Gynaecologists (RCOG) and Société des Obstétriciens et Gynécologues du Canada (SOGC).

STUDY SELECTION

Meta-analysis and clinical trials are included.

RESULTS

Study quality is heterogeneous in general. Hormone therapy inconstantly allows pain relief and prevention of endometrioma and rectovaginal wall nodules recurrence. Available molecules and routes of administration as well as risk benefit balance are evaluated. Data on future perspectives are limited to date and do not allow use in routine.

CONCLUSION

Hormonal treatment of endometriosis relies on combined hormonal contraceptives (using different routes of administration), progestins and particularly the levonorgestrel-releasing IUS, and GnRH analogs as a last option, in combination with an add-back therapy. Promising alternatives are currently under preclinical and clinical evaluation.

Self-management and psychological-sexological interventions in patients with endometriosis: strategies, outcomes, and integration into clinical care

Endometriosis has a multifactorial etiology. The onset and progression of the disease are believed to be related to different pathogenic mechanisms. Among them, the environment and lifestyle may play significant roles. Diet, dietary supplements, physical exercise, osteopathy, massage, acupuncture, transcutaneous electrical nerve stimulation, and Chinese herbal medicine may represent a complementary and feasible approach in the treatment of symptoms related to the disease. In this narrative review, we aimed to examine the most updated evidence on these alternative approaches implicated in the self-management of the disease. In addition, several studies have demonstrated that endometriosis may negatively impact mental health and quality of life, suggesting that affected women may have an increased risk of developing psychological suffering as well as sexual problems due to the presence of pain. In light of these findings, we discuss the importance of integrating psychological interventions (including psychotherapy) and sexual therapy in endometriosis treatment.

Controversies in the Management of Endometrioma: To Cure Sometimes, to Treat Often, to Comfort Always?

Endometriomas are common in reproductive-aged women, but controversy exists regarding their management. PubMed was searched to identify pertinent studies on outcomes of medical and surgical management of endometrioma, with focus on randomized controlled trials and meta-analyses. Surgical excision is more effective than fenestration/coagulation of endometrioma for pelvic pain but decreases antimullerian hormone. It may modestly improve the chances of spontaneous pregnancy, but does not impact chances of success with in vitro fertilization. Oral contraceptive pills improve dysmenorrhea but not dyspareunia or noncyclic pelvic pain. Management of the patient with endometrioma should be individualized based on each patient's particular symptoms and short-term and long-term fertility goals.

Determinant factors of postoperative recurrence of endometriosis: difference between endometrioma and pain

OBJECTIVE

Although the postoperative use of hormonal treatment for endometriosis is recommended in the European Society of Human Reproduction and Embryology guidelines to prevent the recurrence of endometriosis-associated dysmenorrhoea, hormonal treatment may not be necessary for all patients who undergo surgical treatment for endometriosis. The aim of this study was to clarify the determinant factors that predict the recurrence of endometriosis after surgery in order to develop personalized hormonal treatment recommendations. Factors associated with the recurrence of endometrioma and pain were investigated independently to identify the likelihood of recurrence in each individual patient.

STUDY DESIGN

Between 2008 and 2013, 352 patients underwent surgery and were diagnosed with endometriosis based on pathological findings at the study hospital. Among these patients, 191 experienced a recurrence of endometrioma in the absence of pre- or postoperative hormonal treatment. Various clinical factors such as pre-operative pain, intra-operative findings and postoperative improvement of pain were compared between patients who experienced recurrence after surgery and those who did not.

RESULTS

The cumulative 5-year recurrence rate of endometrioma was 28.7% among the 191 patients who did not undergo pre- or postoperative hormonal treatment. Significant differences were detected in maximum tumour diameter, revised American Society for Reproductive Medicine score (r-ASRM score), operative time and operative blood loss between patients in the recurrent endometrioma group and the non-recurrent endometrioma group; only the r-ASRM score was significantly correlated with recurrence of endometrioma in the multivariate analysis. The cumulative 5-year rate of persistent/recurrent pain was 33.4%. There were significant differences in the postoperative improvement of pain between the persistent/recurrent pain group and the non-recurrent pain group according to the univariate and multivariate analyses.

CONCLUSION

This study suggests that the risk factors for recurrence of endometrioma differ from the risk factors for recurrence of pain. The use of postoperative hormonal treatment should be considered based on the dominant risk factors and needs of each patient.

Evaluation of risk factors for the recurrence of ovarian endometriomas

OBJECTIVES

To evaluate the risk factors for the recurrence of ovarian endometrioma after laparoscopic cystectomy.

STUDY DESIGN

Reproductive aged patients who underwent laparoscopic ovarian endometriotic cystectomy and with histopathologically confirmed diagnosis of ovarian endometrioma were evaluated retrospectively. Histopathologic specimens were reevaluated and histopathologic characteristics of ovarian endometriotic cysts (thickness of cyst wall, thickness of fibrosis [ToF], thickness of ovarian tissue, the number of follicles per cyst, the depth of penetration [DoP] of endometrial tissue into the cyst wall) were determined. Along the determined histopathologic findings, demographic characteristics (age at surgery, number of pregnancies), clinical symptoms (dysmenorrhea, infertility), intraoperative findings (revised American Society for Reproductive Medicine [rASRM] stage), imaging features (bilaterality, cyst diameter), and biochemical parameters (Ca125, Ca19.9, Ca15.3) were evaluated as possible risk factors for the recurrence of endometrioma. The variables with p<0.2 in univariate analysis were introduced into regression analysis to determine the risk factors for recurrence.

RESULTS

There were statistically significant differences in age group (≤35 years and >35 years), the ToF and DoP between patients with recurrence and those with no recurrence. In Cox regression analysis, age ≤35 years and DoP were significant risk factors for presence of recurrence. DoP, ToF, preoperative cyst diameters in ultrasonographic examination were inversely correlated with recurrence interval. In multivariate regression analysis, the DoP was found the only significant risk factor for the recurrence interval. 1.2mm of DoP was found as the optimum cut off value for presence of recurrence according to Youden index criteria in ROC curve analyze. The sensitivity (62.9%), specificity (75%) were obtained at the cut off value of 1.2mm for DoP.

CONCLUSION

Histopathological features of ovarian endometriotic cyst may have important roles on predicting the recurrence of the endometrioma. Predicting the recurrence risk of particular patient is very important in future management of the disease. Knowing the recurrence risk of an endometrioma will help in deciding the optimal treatment modalities for each individual patient. High risk patients should be offered appropriate treatments according to the clinical status without delay and low risk patients should be protected from overtreatment.

National German Guideline (S2k): Guideline for the Diagnosis and Treatment of Endometriosis: Long Version - AWMF Registry No. 015-045

In this guideline, recommendations and standards for optimum diagnosis and treatment of endometriosis are presented. They are based on the analysis of the available scientific evidence as published in prospective randomized and retrospective studies as well as in systematic reviews. The guideline working group consisted of experts from Austria, Germany, Switzerland, and the Czech Republic.

Surgical therapy of ovarian endometrioma: recurrence and pregnancy rates

Background and Objectives:

The study was designed to analyze preoperative clinical and surgical findings at enucleation of ovarian endometrioma with their impact on recurrence and pregnancy rates.

Methods:

This is a retrospective study of 550 histologically verified ovarian endometriomas operated on at the Department of Obstetrics and Gynecology, University Hospital Kiel, Germany, between 1995 and 2004. Preoperative data, surgical findings, and postoperative outcomes of 289 cases were analyzed. The average follow-up period was 12.9 years.

Results:

Ovarian endometriomas recurred in 23.9% of patients. Risk factors identified for recurrence of endometriomas were preoperative pain (P = .013), dysmenorrhea (P = .013), larger cyst size (>8 cm), younger age (<25 years), and preoperative cyst rupture. Factors associated with postoperative dysmenorrhea were younger age <25 years (P < .001), nulliparity (P = .020), and lager cyst size >8 cm (P = .048). Recurrence of pain was influenced by previous surgery of endometrioma (P < .05). Laparoscopy had a higher percentage of symptom-free patients than laparotomy did (49.0% vs 33.3%). Additional postoperative hormonal treatment resulted in a higher spontaneous pregnancy rate (41.4% vs 12.6%; P < .001) but a lower recurrence-free interval rate (70.5% vs 82.6%; P = .050) when compared with surgery only.

Conclusions:

We identified preoperative and intraoperative findings associated with higher risk of recurrence of endometrioma, pain, and dysmenorrhea. Patients desiring pregnancy benefited from postoperative hormone treatment, but no favorable results from combined therapy were observed with regard to recurrence rate.

Risk factors for recurrence of ovarian endometriomas after surgical excision

Ovarian endometrioma is a common form of endometriosis, which may cause infertility, dysmenorrhea and pelvic pain in women of reproductive age. Although surgery is the treatment of choice for endometriomas, recurrence poses a formidable frustration. This study investigated potential risk factors of endometriomas recurrence, aiming to better understand its pathogenesis. A total of 307 patients with endometriomas were followed up for an average of 28.6 months and the 1-, 2- and 3-year cumulative recurrence rate was 9.5%, 21.9%, and 29.2%, respectively. Twenty-one potential risk factors for endometriomas recurrence were evaluated using Cox's proportional hazards models. Total revised American Fertility Society (rAFS) score was significantly associated with higher recurrence (OR=1.858, 95% CI=1.122-3.075, P=0.016), as well as younger age at surgery (OR=0.953, 95% CI=0.915-0.992, P=0.020). Semiradical surgical treatment was defined as surgical removal of cyst plus hysterectomy with preservation of bilateral or unilateral ovary, and was a significant factor that was associated with lower recurrence than the conservative surgery (OR=0.318, 95% CI=0.107-0.951, P=0.040). Postoperative pregnancy was favorable factors for disease recurrence (OR=0.217, 95% CI=0.102-0.460, P=0.000). The results suggest that endometrioma recurrence is inversely associated with age at surgery and postoperative pregnancy, and may correlate with total rAFS score and conservative surgery method.

Factors associated with the laterality of recurrent endometriomas after conservative surgery

We evaluated the laterality of primary endometrioma and characteristics of patients according to the laterality of recurrent endometrioma in 140 women with recurrent endometrioma after conservative surgery. Histologically confirmed recurrent endometriomas were found on the left side in 49 patients (35.0%), the right in 44 (31.4%) and bilaterally in 47 (33.6%). The sites of primary endometrioma were not associated with those of recurrent endometrioma, and the recurrence rate in the treated ovary (59.8%) was similar to that of the intact ovary (69.0%) at the primary surgery. Proportions of stage IV endometriosis and posterior cul-de-sac obliteration were higher in patients with bilateral recurrence than in those with unilateral recurrence (p < 0.01 for all comparisons) and in patients with contralateral recurrence than in those with ipsilateral recurrence (p < 0.05 for all comparisons), but no differences were found in other characteristics of participants according to the laterality or pattern of recurrence. In conclusion, the lateral distribution of recurrent endometrioma was not associated with that of the primary lesion, and endometrioma did not recur more frequently in the treated ovary. An advanced stage and the presence of posterior cul-de-sac obliteration were factors associated with bilateral or contralateral recurrence of endometrioma.

Oral contraceptive pills for endometriosis after conservative surgery: a systematic review and meta-analysis

To assess the effects of oral contraceptive pills (OCPs) for endometriosis in women after conservative surgery, we performed a search of PubMed, Embase, ISI Web of Science, Cochrane Library, Scidirect, Chinese VIP, CNKI and WANGFANG database. Randomized controlled trials (RCTs) of OCPs in postoperative medical therapy for endometriosis were collected. Articles published as of January 2013 with no language restriction were identified using defined keywords, and 15 studies comprising 1850 patients were included. There was a significantly higher rate of total endometriosis remission [OR = 2.55, 95% CI (1.68, 3.86), p < 0.00001] and a lower rate of recurrence [OR = 0.31, 95% CI (0.22, 0.45), p < 0.00001] in the OCPs group compared with surgery alone. There appears to be no statistical difference in pregnancy rates between the OCPs group as compared with surgery alone or other hormonal drug treatments in infertility patients. As for the rate of recurrence and complete remission, there were no statistical differences among OCPs and gestrinone, mifepristone or GnRH-a groups. However, OCPs users had less side effects that were more mild as compared with patients using other hormonal treatments.

Is a positive family history of endometriosis a risk factor for endometrioma recurrence after laparoscopic surgery?

A total of 148 patients were followed up for an average of 30.1 ± 17 months following to laparoscopic excision of ovarian endometriomas by a single surgical team. Bivariate and multivariate analyses were used to investigate the association between endometrioma recurrence and several factors, age, body mass index, family history, cyst diameter, number and location, adhesions or peritoneal implants, occurrence of spillage, postoperative treatment with gonadotropin-releasing hormone agonist, or pregnancies. The overall recurrence rate of the endometriomas was 18.2%. At bivariate analysis, recurrence rate was significantly higher in patients with a positive family history of endometriosis (40% vs 14.8%). Recurrence was also more frequent, albeit nonsignificantly, in patients with a history of dysmenorrhea, intraoperative spillage, and postoperative hormonal suppression. At multivariate analysis with logistic regression, a positive family history of endometriosis was the only variable independently associated with endometrioma recurrence following laparoscopic removal (odds ratio 3.245; 95% confidence interval: 1.090-9.661).

Postoperative recurrence and fertility after endometrioma ablation using plasma energy: retrospective assessment of a 3-year experience

STUDY OBJECTIVE

To assess recurrence and pregnancy rates in women with ovarian endometrioma treated via ablation using plasma energy.

DESIGN

Retrospective non-comparative pilot study including 55 patients treated during 28 months, with prospective recording of data (Canadian Task Force classification II-2).

SETTING

Tertiary referral center.

PATIENTS

Fifty-five consecutive women with pelvic endometriosis in whom ovarian endometriomas were managed solely via ablation using plasma energy. The minimum follow-up was 1 year.

INTERVENTION

Endometrioma ablation using plasma energy.

MEASUREMENTS AND MAIN RESULTS

Information was obtained from the database of the North-West Inter Regional Female Cohort for Patients with Endometriosis, based on self-questionnaires completed before surgery, surgical and histologic data, and systematic recording of recurrences, pregnancy, and symptoms. Recurrences were assessed using pelvic ultrasound examination. Mean (SD) follow-up was 20.6 (7.2) months (range, 12-39 months). In 75% of patients, deep infiltrating endometriosis was treated, and 40% had colorectal involvement. Preoperative infertility was recorded in 42% of patients. The rate of postoperative recurrence was 10.9% for the entire series. Of 33 women who wished to conceive, 67% became pregnant, spontaneously in 59%. Time from surgery to the first pregnancy was 7.6 (4.3) months. After discontinuation of postoperative hormone therapy, the probability of not conceiving at 12 months was 0.36 (95% confidence interval, 0.19-0.53), and at 24 months was 0.27 (95% confidence interval, 0.12-0.44).

CONCLUSIONS

Recurrence and pregnancy rates are encouraging in that they seem comparable to the best reported results after endometrioma cystectomy. Plasma energy may have an important role in the management of ovarian endometrioma in women seeking to conceive. Patients most in need of surgical procedures that can spare ovarian parenchyma, such as those with bilateral endometriomas or a history of ovarian surgery, may particularly benefit from ablation using plasma energy.

Endometriosis, dysmenorrhoea and diet

OBJECTIVE

To review the literature on the effects of diet on endometriosis and dysmenorrhoea.

STUDY DESIGN

A systematic search for trials investigating a relationship between diet and endometriosis/dysmenorrhoea was undertaken, and 23 studies were included in this review.

RESULTS

Data on the relationship between diet and endometriosis were limited to 12 trials, three of which were animal studies, resulting in a total of 74,708 women. One large study (n=70,709) found a relatively strong association between endometriosis and trans-fatty acid consumption, and a lower risk of endometriosis with increased consumption of long-chain omega-3 fatty acids. The latter finding was also supported by smaller studies. No further dietary recommendations for reducing the risk of endometriosis were possible, and results for intake of vegetable, fibre and fruit were equivocal. The relationship between diet and dysmenorrhoea was investigated in 11 trials with different designs, including a total of 1433 women. Intake of fish oil seemed to reduce dysmenorrhoea.

CONCLUSION

The literature on endometriosis and dysmenorrhoea in relation to diet is sparse, yielding equivocal results on specific elements. Overall, however, the literature suggests that specific types of dietary fats are associated with endometriosis and/or dysmenorrhoea, thereby indicating that there may be modifiable risk factors. Further research is recommended on both subjects.

New trends for the medical treatment of endometriosis

INTRODUCTION

Endometriosis is a benign sex hormone-dependent gynecological disease, characterized by the presence and growth of endometrial tissue outside the uterus; it affects 10% of women of reproductive age and is associated with infertility and pain. Treatment of endometriosis involves conservative or radical surgery, or medical therapies. The goals for endometriosis treatment may be the relief of pain and/or a successful pregnancy achievement in infertile patients. Treatment must be individualized with a multidisciplinary approach. The classical treatments carry adverse side effects and in some cases a negative impact on quality of life. New agents promise a distinct perspective in endometriosis treatment.

AREAS COVERED

The aim of this paper is to systematically review the literature evidence of new medical treatments for endometriosis, defined as pharmacological treatments not yet commonly available and currently under investigation.

EXPERT OPINION

These new medical therapies would be used associated with surgical treatment and, in the future, will render possible the association of hormone therapy with non-hormonal treatment for endometriosis.

Ultrasound ovarian assessments after endometrioma ablation using plasma energy

We performed a retrospective three-dimensional ultrasound evaluation of the ovarian features in ten women with no previous ovarian surgery who benefited from ablation by plasma energy for unilateral endometriomas greater than to 30 mm in diameter. Values of ovarian volume and antral follicle count in operated ovaries were decreased by an average 12% and 18%, respectively, suggesting that endometrioma ablation using plasma energy spares the underlying ovarian parenchyma.

Vaporization of ovarian endometrioma using plasma energy: histologic findings of a pilot study

In ten ovarian endometriomas of diameter exceeding 30 mm, managed by complete vaporization of the inner surface using plasma energy followed by cystectomy, we performed histologic evaluation of the depth of necrosis and the effectiveness of endometrial tissue ablation. We observed that plasma energy allows the ablation of endometrial tissue with minimal damage to the ovarian parenchyma, which suggests that this technique might be of particular interest for women with risk factors of postoperative ovarian reserve impairment, such as recurrent and bilateral endometriomas.

Hormonal contraceptives and endometriosis/adenomyosis

Over the past 50 years hormonal contraceptives have gradually developed to be cost-effective medical treatment modalities for primary and secondary therapy of endometriosis/adenomyosis. This is particularly true for the various estrogen/progestogen combinations as monophasic - particularly progestogen-dominant - preparations in cyclic, long-cyclic and continuous treatment forms. An alternative is the progestogen-only therapy used continuously. Therapeutic effects have been shown for peritoneal, ovarian and deep-infiltrating endometriosis as well as for adenomyosis. An individualized, medical long-term treatment concept to control endometriosis/adenomyosis-related symptoms, endometriosis/adenomyosis development and minimizing the recurrence rate needs to be further studied in women, who do not desire to become pregnant.

Dietary therapy: a new strategy for management of chronic pelvic pain

Chronic pelvic pain (CPP) can be identified as a chronic nociceptive, inflammatory and neuropathic pain characterised by spontaneous pain and an exaggerated response to painful and/or innocuous stimuli. This pain condition is extremely debilitating and usually difficult to treat. Currently, the main approaches to treatment include counselling supported by reassuring ultrasound scanning or psychotherapy, attempting to provide reassurance using laparoscopy to exclude serious pelvic pathology, hormonal therapy and neuroablative treatment to interrupt nerve pathways. Dietary supplementation has been suggested as a means to treat chronic medical illnesses that are poorly responsive to prescription drugs or in which therapeutic options are limited, costly or carry a high side-effect profile. A comprehensive search of the PubMed database was performed using the search terms 'chronic pelvic pain', 'oxidative stress', 'antioxidants' and 'dietary therapy'. The systematic review focuses on both randomised and non-randomised controlled trials from 2005 onwards, in which CPP was the end point. Given the complexity and not well-understood aetiology of CPP, its treatment is often unsatisfactory and limited to partial symptom relief. Dietary therapy with antioxidants improves function of the immune system and in fighting free radical damage. Agents with antioxidant activity are able to improve CPP without undesired effects and any important metabolic changes associated with hormonal suppression therapy. In conclusion, dietary therapy with antioxidants could be considered as a new effective strategy in the long term for CPP, and may be better accepted by patients. Further randomised trials with larger series and long-term follow-up to confirm these observations are needed.

Management of deep endometriosis

Deep endometriosis is still a challenging disease in terms of diagnosis and treatment. About 10-12% of women of reproductive age will have a form of endometriosis. This can affect pelvic as well as extra pelvic locations. Risk of malignant transformation has been studied over a long period of time. Medical and surgical treatments can be proposed to patients for endometriosis-associated pain depending on the severity of symptoms and location of the disease. Results and outcomes are different according to different publications. Understanding of the benefit of surgical treatment on fertility is increasing. The place of medical and surgical treatment in recurrent symptoms or disease is also of interest. Presented here is a review on the management of endometriosis in the light of recent data. Further investigations in many fields of endometriosis are still required.

Medication and transference in psychoanalytically oriented psychotherapy of the borderline patient

The regressive potential of the borderline patient has been recognized ever since the term was first introduced by Adolph Stern in 1938. He believed these patients were "too ill for classical psychoanalysis," and indeed almost all who have written on this subject have supported Stern's view, recognizing the severe regressive potential of a borderline patient in unmodified psychoanalysis. Taking medication is not generally considered to be a particularly regressive experience. It should be remembered, however, that for many patients and especially for patients with borderline personality disorder, medication can be both an overvalued hope and a terrifying assault. Thus, although the pharmacologic action of the medication may help to integrate the patient's ego functioning, the very taking of the medication may at the same time initiate subtle and unanticipated regressive drives. Two forces are then set in motion with potentially different effects. In a treatment where the same physician is prescribing medication and doing psychotherapy, the common pathway of these forces is transference. Thus, pharmacologic action may modify transference. And more importantly, because it is less easily recognized, transference issues may affect the patient's subjective experience of the action of the medication. For this reason, it is particularly important that not only diagnostic issues but also transference issues be understood before medication is prescribed.(ABSTRACT TRUNCATED AT 250 WORDS)