Despite available studies supporting standard hormone therapy for women with endometriosis and postsurgical menopause, there is still concern that estrogens may induce a recurrence of the disease and its symptoms. The evidence in the literature is insufficient to suggest depriving symptomatic patients of this treatment. In a systematic review evaluating pain and disease recurrence in women with endometriosis who used hormone therapy for postsurgical menopause, two randomized trials were included (465). In one trial, recurrence of pain in women with a conserved uterus was not significantly different in 1 of 11 women treated with continuous tibolone (2.5 mg per day), or in 4 of 10 women receiving nonstop transdermal application of 17-β estradiol (0.05 mg per day) combined with cyclic medroxyprogesterone acetate (10 mg per day) for 12 days per month (466). In the second trial, recurrence of pain was not significantly different in any of 57 patients in the no-treatment arm, or in 4 of 115 women receiving sequential administration of estrogens and progesterone with two 22-cm patches applied weekly to produce a controlled release of 0.05 mg per day, combined with oral administration of micronized progesterone administered orally (200 mg per day) for 14 days with a 16-day interval free of treatment (5,329). In this study, the endometriosis recurrence and reoperation rate were comparable in both groups (2 of 115 of the treatment group; 0 of 57of the no-treatment group) (329).
Endometriosis tends to recur unless definitive surgery is performed. Pain recurs within 5 years in about one in five patients with pelvic pain treated by complete laparoscopic excision of visible endometriotic lesions (467). The endometriosis recurrence rate is about 5% to 20% per year, reaching a cumulative rate of 40% after 5 years. Medical treatment appears to have limited and inconsistent effects when used for only a few months after conservative procedures (468). Data on the benefit of prolonged drug regimens with OCs or progestogen are lacking. The current ASRM classification system has low value to predict pain recurrence and endometriosis relapse after conservative surgical treatment (469).
The medium-term outcome of hysterectomy for endometriosis-associated pain is satisfactory; the probability of pain persistence after hysterectomy is 15% and risk of pain worsening is 3% to 5%, with a six times higher risk of further surgery in patients with ovarian preservation as compared to concomitant bilateral ovarian removal (470). At least one ovary should be preserved in young women, especially in those who cannot or will not receive estrogen-progestin therapy (471). The risk of recurrence of endometriosis during hormonal therapy seems marginal if combined preparations or tibolone are used and estrogen-only treatments are avoided (471).
The rate of recurrence increases with the stage of disease, the duration of follow-up, and the occurrence of previous surgery (14,472–475). The likelihood of recurrence appears to be lower when endometriosis is located only on the right side of the pelvis than when the left side is involved (475). The risk of endometriosis recurrence is significantly correlated to the age of the patient. The younger the patient is at the moment of the diagnosis the higher the risk of recurrence. Higher recurrence rates in younger patients seem to justify a more radical treatment in this group (288). Persistence of dysmenorrheal and nonmenstrual pelvic pain after excision of endometriosis can be related to adenomyosis as defined by a thickened (>11 mm) uterine junctional zone on MRI (476). More data are needed to define the best therapeutic option in women with recurrent endometriosis, in terms of pain relief, pregnancy rate, and patient compliance (470).
Prevention of Recurrence