Effect on endometriosis recurrence with postoperative hormonal suppression

Postoperative hormonal suppression had a statistically significant effect on reducing endometriosis recurrence and improving pain, according to a systematic review and meta-analysis published in the journal Human Reproduction Update.

“As surgeons, our primary goal is to make patients feel better and we often accomplish this by surgically treating endometriosis,” said co-author Ally Murji, MD, MPH, an associate professor of ob/gyn at the University of Toronto and Mount Sinai Hospital in Toronto, Canada. “However, it is especially disheartening, despite our best surgical efforts, when disease recurs and patients relapse.”

The authors sought to evaluate whether postoperative hormonal suppression decreases disease recurrence, compared with placebo/expectant management.

MEDLINE, Embase, Cochrane CENTRAL and Web of Science databases were searched from inception to March 2020 for randomized clinical trials (RCTs) and prospective observational cohort studies of premenopausal women undergoing conservative surgery and initiating hormonal suppression within 6 weeks postoperatively with one of the following medical therapies: combined hormonal contraceptives, progestins, levonorgesterel-releasing intrauterine system (LNG-IUS) and gonadotropin-releasing hormone (GnRH) agonists.

The review consisted of 17 studies (13 RCTs and 4 cohort studies), totaling 2,137 patients: 1,189 receiving postoperative suppression and 948 controls.

The mean follow-up ranged from 12 to 36 months, with outcomes assessed at a median of 18 months postoperatively.

Among 14 studies (11 RCTs, 3 cohort studies; 1,766 patients total), there was a significantly decreased risk of endometriosis recurrence in patients receiving postoperative hormonal suppression compared with expectant management/placebo: relative risk (RR) 0.41; 95% confidence interval (CI): 0.26 to 0.65.

“However, when we limited the analysis to only RCTs, we found that the risk of postoperative endometriosis recurrence was consistently decreased with hormonal suppression,” Dr. Murji told Contemporary OB/GYN.

In addition, among seven studies (6 RCTs, 1 cohort study; 652 patients total), patients receiving postoperative hormonal suppression achieved significantly lower pain scores compared with controls: standard mean difference (SMD) -0.49; 95% CI: -0.91 to -0.07.

“Our review provides new evidence that postoperative hormonal suppression decreases endometriosis recurrence and pain,” Dr. Murji said. “This contradicts the last Cochrane review on the topic.”

Furthermore, although there was significant heterogeneity in the studies included in the review, “I am confident in the results,” he said. “We found that there is only a 4% probability that any future RCT would contradict our findings.”

Dr. Murji was surprised by the magnitude of the effect. “As few as eight women would need to be treated with postoperative hormonal suppression for at least 6 months to prevent one endometriosis recurrence,” he said.

Dr. Murji said it is essential that clinicians educate their patients that endometriosis is a chronic condition and that surgery is not a panacea. Extensive patient counseling before surgery is necessary to educate patients and manage their expectations, according to Dr. Murji. “For patients not seeking to conceive immediately after surgery, I offer hormonal suppression,” he said. “The plan for postsurgical prevention is also formalized preoperatively.”

Due to the recent COVID-19 pandemic-related surgical delays, “there is increased opportunity to help patients find the ideal medical treatment option that aligns with their individual needs so as to bridge patients to their surgery and thereafter,” he said.

Dr. Murji and his colleagues have found that hormonal contraceptives, progestins, the LNG-IUS and a GnRH agonists are all consistently effective in decreasing pain and disease recurrence.

In particular, the LNG-IUS, which can be inserted under laparoscopic visualization at the time of surgery, “avoids some of the issues related to discomfort/placement and provides excellent long-term suppression,” Dr. Murji said.

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Dr. Murji serves on the speakers’ bureau/advisory boards of Abbvie, Allergan, Bayer, Hologic, and Pfizer.

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Reference

1. Zakhari A, Delpero E, McKeown S, et al. Endometriosis recurrence following post-operative hormonal suppression: a systematic review and meta-analysis. Hum Reprod Update. Published online October 6, 2020. doi:10.1093/humupd/dmaa033