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

Abstract

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], levonorgestrelreleasing 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.

Extrinsic Adenomyosis Is Associated With Postoperative Recurrence of Ovarian Endometrioma

“…Extrinsic adenomyosis is associated with more severe DIE lesions and higher ASRM scores. It will be beneficial for patients of coexistence of adenomyosis and endometriosis to apply individual management to achieve better efficacy ( 39 ). The coexistence of adenomyosis and endometriosis must be part of the decision-making process for DIE patients when they are presented on abnormal clinical symptoms and long-term infertility ( 40 ).…”

Long-term efficacy and safety of levonorgestrel-releasing intrauterine system as a maintenance treatment for endometriosis

“…[ 20 ] According to a recent study, a short-term hormone therapy of <6 months is not effective in preventing recurrence. [ 16 ] Therefore, recent guidelines recommend implementing a maintenance therapy for at least 18 to 24 months after surgery. [ 21 ] For successful long-term maintenance therapy, not only the efficacy of treatment, but also the tolerability of treatment and the compliance of patients must be considered.…”

“…According to a recent systematic literature review of randomized controlled studies, LNG-IUS can significantly reduce the risk of recurrence of pain symptoms [15] and endometrioma compared with place. [16] Many cohort studies comparing with other types of hormonal therapy have found that effects of LNG-IUS on pain relief and recurrence prevention are similar to those of combined oral contraceptives or dienogest. [17][18][19] The present study found that LNG-IUS was effective in preventing the recurrence of dysmenorrhea throughout a 10-year period and that its effect was similar to those of other types of hormone therapy.…”

Dienogest as a Maintenance Treatment for Endometriosis Following Surgery: A Systematic Review and Meta-Analysis

“…However, the study did not compare DNG maintenance treatment with other treatments, such as LNG-IUS or GnRH-a; therefore, it gave no liberty to choose a suitable treatment according to patient needs. Moreover, Wattanayingcharoenchai et al ( 19 ) suggested that there was no evidence supporting hormonal treatment for the postoperative prevention of endometriosis recurrence in the Network Meta-Analysis of RCTs. This was contrary to the evidence from cohort studies, which showed the protective effect of progesterone, especially for long-term management after surgery.…”

“…DNG moderately inhibits the H-P-O axis, thereby inhibiting estrogen production ( 19 ). Similarly, it downregulates prostaglandin E2, inflammatory cytokines [including interleukin (IL)-6, IL-8, monocyte chemoattractant protein-1], estrogen synthetase aromatase, and neuroangiogenesis factors (such as vascular endothelial growth factor (VEGF) and nerve growth factor) in endometriotic cells to decrease recurrence and alleviate pain ( 19 , 20 ).…”