Some randomized controlled studies suggest that postoperative hormonal treatment can be useful in delaying the recurrence of endometriosis and/or pelvic pain. One study supported the long-term postoperative use of OCs to reduce the frequency and the severity of recurrent endometriosisrelated dysmenorrhea (339). The prevention of endometriosis-related pain recurrence by postoperative long-term (24 months) cyclic and continuous administration of OCs was compared to no treatment in women after surgery for ovarian endometrioma. A significant reduction in recurrence rate and VAS scores for dysmenorrhea was evident in the continuous users versus the other groups at 6 months, and in cyclic users versus nonusers at 18 months postoperatively. No significant differences in recurrence rate and VAS scores for dyspareunia and chronic pelvic pain were demonstrated among the groups. The increase of VAS scores for dysmenorrhea, dyspareunia, and chronic pelvic pain during the postoperative follow-up of 6 to 24 months was significantly higher in nonusers than in the users (339).
In a second study, long-term cyclic and continuous postoperative use of OCs was shown to effectively reduce and delay endometrioma recurrence (340). The crude recurrence rate within 24 months was significantly lower in cyclic (14.7%) and continuous users (8.2%) compared with nonusers (29%). The recurrence-free survival was significantly lower in nonusers compared with cyclic and continuous users. The mean recurrent endometrioma diameter at first observation and the mean diameter increase every 6 months of follow-up were significantly lower in cyclic and continuous users compared with nonusers, whereas no significant differences between cyclic users and continuous users in terms of endometrioma recurrence were demonstrated (340).
In a third study, women who underwent conservative pelvic surgery for symptomatic endometriosis stages III and IV (r-AFS) were treated postoperatively during 6 months with either placebo, GnRH agonist (triptorelin or leuprorelin, 3.75 mg every 28 days), continuous estroprogestin (ethinylestradiol, 0.03 mg plus gestodene, 0.75 mg) or dietary therapy (vitamins, minerals salts, lactic ferments, fish oil) (341). At 12 months after surgery, patients treated with postoperative hormonal suppression therapy showed a lower VAS score for dysmenorrhea than patients in the other groups. Hormonal suppression therapy and dietary supplementation were equally effective in reducing nonmenstrual pelvic pain. Postoperative medical and dietary therapy allowed a better quality of life when compared to placebo treatment (341).
In a systematic review to determine whether postoperative use of an levonorgestrel intrauterine system in women with endometriosis improves pain symptoms associated with menstruation and reduces recurrence compared with surgery only, placebo, or systemic hormones, one small randomized controlled trial was identified showing a statistically significant reduction in the recurrence of painful periods in the levonorgestrel intrauterine system treated group compared with the control group receiving a GnRH agonist (OR 0.14; 95% CI, 0.02–0.75) (342,343). The proportion of women who were satisfied with their treatment was higher in the levonorgestrel intrauterine system treated group than in the control group, but this difference did not reach statistical difference (OR 3.00; 95% CI, 0.79–11.44) (342,343). In another small randomized trial, postsurgical treatment with either levonorgestrel intrauterine system or depot MPA for 3 years indicated symptom control and recurrence were comparable, but compliance and change in bone mineral density were better in the levonorgestrel intrauterine system treated group than in the depot MPA group (344).