Postoperative Hormonal Therapy After Surgical Excision of Deep

Postoperative Hormonal
Therapy After Surgical Excision

of Deep Endometriosis
SUBTITLE
Introduction
Deep Peritoneal Endometriosis
is an inltrative commonly located
disease form that in the most
may involve vital declivous part of
structures the pelvis
therapeutic
can cause
management
signicant chronic
remains
pelvic pain
controversial
Surgery and hormonal
treatment: from
antagonism to mutual aid
Surgery in deep lesions
deep lesions are typically
inltrate adjacent or ligaments
concomitant presence of
adhesions and brosis further
complicates surgery
signicant peri-operative risks

and long-term sequelae
Noteworthy, a recent study comparing surgery
and medical treatment in women with
rectovaginal lesions documented a more rapid
improvement in women receiving surgery but
the difference between the two approaches
lessens with time and, at one year follow-up,
pain symptoms were similar in the two study
groups
Medical Treatment
Consent to achieve good pain relief with very modest side-
effects and risks
The focus should be on symptoms relief and quality of life rather
than on lesions removal
However, surgical removal is not and presumably will never be
denitely abandoned
Regardless of the vision of the disease and the precise role of
surgery, a main priority in the eld is prevention of recurrences
after the intervention
Recurrence Rate
Endometriosis is indeed a chronic disease and recurrences are
unfortunately common
Guo estimated that the rate of recurrences at two and ve years
is 20% and 4050%, respectively
Meuleman et al. reported a rate of recurrence in affected
women varying between 5% and 25%, with most studies with a
follow-up >2 years reporting a rate of about 10%
The goal of post-operative hormonal
treatment is to improve the effectiveness
of the intervention in terms of symptom
relief and, most importantly, to prevent
recurrence
The failure of adjuvant
therapy
Endometriosis malignancy
Resemblance with cancer (micro lesion) leads to the hypothesis
that a 36 months course of medical therapy immediately after
surgery could reduce recurrences
Available clinical evidence clearly denies the effectiveness of this
approach
Chemotherapic agents interfere with cell cycle proliferation and
are thus able to destroy micro-metastasis that can be present at
the time of surgery
Hormonal therapy does not damage endometriotic cells. It just
causes a transient state of quiescence that vanishes as soon as
medical therapy is suspended.
Tertiary prevention
Endometriosis lifelong treatment
Ovarian endometriomas recurrences oral contraceptive
assumption after surgery for ovarian endometrioma markedly
prevents recurrence of these cysts
Pain symptoms Evidence is robust for the prevention of
dysmenorrhea recurrence but nor for other pain symptoms,
using oral contraceptives, medroxiprogesterone acetate (MPA)
and a levonorgestrel-releasing IUD
Post-op Hormonal Treatment Data
large prospective study of women who were operated on for
rectovaginal endometriotic nodules with the shaving technique
and who were subsequently given norethisterone acetate
(NETA) 5 mg daily until they wished to conceive
n = 221, recurrence was noted in only four cases (2%). In those who
attempted to conceive but failed to obtain a pregnancy (n = 60),
recurrence was reported in 12 cases (20%) (p < 0.001)
Malzoni et al. recently reported their experience with

laparoscopic segmental bowel resection for deep inltrating
endometriosis in 248 women
Pelvic relapse was found in 50% of cases especially in women
without hormonal suppression. Interestingly, recurrences were in
the form of endometriomas and adhesions with no recurrent deep
lesions
Conclusions
A 36 months course of post-surgical adjuvant therapy for
endometriosis in general and deep endometriosis in particular is
unlikely to be effective
The available data on post-surgical medical therapy for women
operated on for deep endometriosis is encouraging but very scanty
Women operated on for deep peritoneal endometriosis indeed face a
consistent risk of endometrioma development or pain recurrence
given the effectiveness of prolonged medical therapy for deep
peritoneal endometriosis in general, the same treatments may be
effective also in the prevention of recurrences in operated cases
Data on the most suitable pharmacological agent to be used is
insufcient
specic drug to be chosen is not a primary point. the crucial aspect
here is the adherence to long-term assumption
Thank You

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Postoperative Hormonal

Therapy After Surgical Excision

signicant peri-operative risks

Malzoni et al. recently reported their experience with

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