Evaluation and management of endometriosis

The initial diagnostic investigations for endometriosis are physical examination and pelvic ultrasound. The pelvic examination should include a speculum examination and vaginal palpation. Mobility, fixation and/or tenderness of the uterus and site-specific tenderness in the pelvis should be evaluated. Transvaginal ultrasound and pelvic magnetic resonance imaging are recommended to evaluate the extent of the endometriosis and to determine whether any urinary tract or bowel procedures might also be required during surgical resection. Quality of life should be assessed by using the Endometriosis Health Profile-30, its short version EHP-5 or the generic quality of life questionnaire SF-36. Management of endometriosis is recommended when it has a functional impact (pain, infertility) or causes organ dysfunction. Many gynecological societies have published different guidelines for the evaluation and management of endometriosis. However, the complexity of this disease together with the different available treatments lead to significant discrepancies between the recommendations. Postmenopausal endometriosis should be considered when a patient has a history of symptoms before menopause including dysmenorrhea, dyspareunia, dyschezia, infertility and chronic pelvic pain. Malignant transformation of endometriosis is estimated to occur in about 0.7-1.6% of women affected by endometriosis. Endometriosis is associated with an increased risk of ovarian cancer, specifically clear cell, endometrioid and low-grade serous types.

Effect of the mode of delivery on the risk of endometriosis recurrence: a retrospective cohort study

OBJECTIVE

To evaluate the risk of endometriosis recurrence according to the mode of delivery (cesarean section vs. vaginal birth) in patients who had become pregnant with a live birth after surgery for endometriosis.

DESIGN

A retrospective cohort study. A Cox proportional-hazards regression was performed to evaluate the risk factors for endometriosis recurrence at 36 months of follow-up after the last pregnancy.

SETTING

Academic hospital.

PATIENT(S)

Patients who have had ≥1 pregnancy with a live birth following conservative surgery for ovarian endometriosis performed from January 2009 to December 2016 at our institution.

INTERVENTION(S)

Patients who underwent ≥1 cesarean section after surgery for endometriosis.

MAIN OUTCOME MEASURES

The recurrence rate of endometriosis after live-birth pregnancies obtained after the first surgery for endometriosis.

RESULTS

Patients with a history of ≥1 cesarean section after surgery for endometriosis have a higher risk of endometriosis recurrence than the patients who have had a vaginal birth, with an adjusted hazard ratio of 2.25 (95% confidence interval, 1.27-3.96).

CONCLUSION

A cesarean section after surgery for endometriosis is associated with a twofold high risk of endometriosis recurrence with respect to vaginal birth. A different follow-up approach may be needed in those patients, and avoiding inappropriate indications for cesarean sections in pregnant patients with a history of surgery for endometriosis is necessary.

Menopausal hormonal therapy in surgically menopausal women with underlying endometriosis

OBJECTIVE

This study aimed to investigate the relationship between menopausal hormone therapy (MHT) and endometriosis recurrence in women who underwent hysterectomy with bilateral salpingo-oophorectomy to treat endometriosis.

METHOD

This retrospective cohort study included 330 women who underwent definitive surgery to treat endometriosis during 1996-2012. Follow-up data until December 2018 were analyzed. Patients were grouped as MHT non-users (non-MHT, n = 43), estrogen-only therapy (ET, n = 230), estrogen-progestogen therapy (EPT, n = 39) and tibolone (n = 18).

RESULTS

The mean age at surgery was 41.5 ± 5.3 years. The overall median follow-up duration was 6.0 years (interquartile range [IQR]: 3.0-10.4), and the median duration of MHT use was 66.0 months (IQR: 36.0-116.3). The overall recurrence rate was 3.0% (95% confidence interval: 1.5-5.5) and there was no significant difference in recurrence among the study groups. Disease recurrence resolved after MHT discontinuation, or change in MHT type and/or dose.

CONCLUSIONS

No significant association between MHT use and endometriosis recurrence was found in this study. The endometriosis recurrence rate was non-significantly different between ET and EPT. Recurrent endometriosis can be successfully treated without invasive measures. No study patients had malignant transformation after a median follow-up of 6 years. Our findings suggest that any of the three evaluated MHT regimens can be used in surgically menopausal Thai women with underlying endometriosis.

Recurrent endometriosis: a battle against an unknown enemy

Recurrence of endometriosis after conservative surgery is not an uncommon finding. There is no uniformity, however, on what the term 'recurrence' means. Recurrence is variously defined in the literature as the relapse of pain, clinical or instrumental detection of an endometriotic lesion, repeat rise in CA 125 levels, or evidence of recurrence found during repeat surgery. Consequently, the reported recurrence rate varies widely (0-89%) in the different series, depending on its definition and the type of study performed. As endometriosis recurrence seems to be an indeterminate enemy, we set out to examine exactly what we were fighting in our everyday battle. In this narrative review, we aimed to seek an answer to questions related to endometriosis recurrence, some of which are often asked by our patients.