Post-operative Use of Oral Contraceptive Pills for Prevention of Anatomical Relapse or Symptom-recurrence after Conservative Surgery for Endometriosis

R. Seracchioli; M. Mabrouk; L. Manuzzi; C. Vicenzi; C. Frascà; A. Elmakky; S. Venturoli

Disclosures

Hum Reprod. 2009;24(11):2729-2735. 

In This Article

Abstract and Introduction

Abstract

Background Endometriosis recurrence after conservative surgery is not infrequent. Variable regimens of hormonal therapy have been proposed as adjuvant post-operative measures for prophylaxis against recurrence. Among these, the combined oral contraceptive pills (OCP), represents a valuable option in terms of safety and tolerability for long-term use. The objective of this review is to evaluate the effect of post-operative use of OCP in preventing symptom recurrence, and/or anatomical relapse of endometriosis.
Methods A systematic search of Medline identified seven studies evaluating post-operative OCP treatment on prevention of endometriosis recurrence.
Results A reduction in anatomical relapse rate was observed when oral contraceptive therapy was administered for more than 1 year after conservative surgery. Post-operative use of OCP was associated with a reduction in frequency and intensity of dysmenorrhoea recurrence. No association was found between OCP therapy and dyspareunia prevention, although the effect of OCP on chronic pelvic pain was conflicting.
Conclusion Long-term OCP therapy can be a reliable adjuvant post-operative measure to prevent or reduce frequency/severity of recurrent dysmenorrhoea and anatomical relapse of endometriosis. Since both continuous and cyclic OCP administration regimens seem to have comparable effects, the choice of regimen can be modulated according to patient preferences. The protective effect seems to be related to the duration of treatment.

Introduction

Endometriosis is a chronic gynaecological condition that affects women of reproductive age, causing infertility and pelvic pain. The pain may occur during menstrual bleeding (dysmenorrhoea), during sexual intercourse (dyspareunia) or not following any cyclical pattern (chronic pelvic pain) (Fauconnier and Chapron, 2005). If endometriosis involves the rectum or the bladder, symptoms as dyschezia or dysuria may respectively occur (Child and Tan, 2001; Milingos et al., 2003). Women affected by symptomatic endometriosis often report a significant reduction in their quality of life (Jones et al., 2004).

Among the different endometriotic pelvic implants, ovarian endometrioma is the most common, affecting around 55% of patients (Liu et al., 2007).

Excisional surgery is the treatment of choice, as it significantly reduces painful symptoms and improve quality of life in 67–80% of patients (Abbott et al., 2004). A frustrating aspect of conservative surgery, however, is the recurrence of endometriotic implants and painful symptoms at a long-term follow-up. It has been observed a cumulative rate of endometrioma recurrence of 12–30% after 2–5 years of follow-up (Busacca et al., 1999; Jones and Sutton, 2000; Chapron et al., 2002; Fedele et al., 2006; Guo, 2009). Recurrence or worsening of pain has been observed in 7–30% of patients within 3 years of surgery, increasing to 40–50% after 5 years (Valle and Sciarra, 2003). Therefore, over recent years there has been particular interest in adjunctive post-operative hormonal therapy that reduces recurrence of endometriosis.

As endometriotic tissue is hormonally sensitive, hormonal therapies could be effective in post-operative management of endometriosis (Child and Tan, 2001). It must be stressed, however, that hormones are not curative and endometriosis usually relapses at treatment suspension; therapies need therefore to be administered for long time. Oral contraceptives may be the best hormonal pharmacological choice, as they are safe, well tolerated, relatively inexpensive and can be administered for long periods (Vercellini et al., 2008a). Oral contraceptive pills (OCP), both in cyclic and continuous regimen, have been used for years in clinical practice as adjuvant post-operative measure, even without a high-level evidence of their effectiveness (Rice, 2002; Rodgers and Falcone 2008). This review aims to evaluate the post-operative use of oral contraceptive therapy, both in cyclic and continuous administration, in preventing endometriosis recurrence.

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