Endometriosis recurrence following post-operative hormonal suppression: a systematic review and meta-analysis.
Level 1 - systematic review of randomized trials
Systematic review and meta-analysis predominantly of randomized controlled trials (13 RCTs, 4 prospective cohort studies)
PubMed 33020832 · doi:10.1093/humupd/dmaa033
What was done
Authors searched MEDLINE, Embase, Cochrane CENTRAL, and Web of Science through March 2020 for randomized controlled trials (RCTs) and prospective observational cohort studies. They included pre-menopausal women undergoing conservative surgery for endometriosis (conserving at least one ovary) who initiated hormonal suppression within 6 weeks post-operatively (combined hormonal contraceptives [CHC], progestins, androgens, levonorgestrel-releasing intra-uterine system [LNG-IUS], or GnRH agonists/antagonists) versus expectant management or placebo. Studies with under 12 months follow-up were excluded. Primary outcome was recurrence (imaging or symptoms) at ≥12 months; secondary outcome was pain change.
What was found
Seventeen studies were included (13 RCTs, 4 cohort studies; 2,137 patients: 1,189 suppression, 948 controls) evaluating CHC (6 studies, n = 869), progestin (3 studies, n = 183), LNG-IUS (2 studies, n = 94), and GnRH agonists (9 studies, n = 1,237). Median follow-up was 18 months (range 12–36 months). Hormonal suppression significantly reduced recurrence risk compared to control (relative risk [RR] 0.41, 95% CI: 0.26 to 0.65; 14 studies, 1,766 patients; I2 = 68%). Suppression also reduced pain scores (standardized mean difference [SMD] -0.49, 95% CI: -0.91 to -0.07; 7 studies, 652 patients; I2 = 68%).
Why it matters
Post-operative medical suppression within 6 weeks of conservative surgery substantially lowers disease recurrence and symptom burden for women not seeking immediate conception.
Limits
Moderate-to-high statistical heterogeneity was present for recurrence and pain outcomes (both I2 = 68%). The primary outcome combined imaging-based and symptom-based recurrence criteria. Four included studies were non-randomized cohort studies, and search was restricted to English-language publications.
Cited by
- partial Following laparoscopic surgical excision of endometriosis, post-operative hormonal suppression is required to prevent lesion recurrence.