There is no evidence that hormonal suppression either before or after surgery for endometriosis is associated with a benefit

Endometriosis is caused by the lining of the uterus (endometrium) spreading outside the uterus. It can cause pelvic pain, painful periods and infertility. Common treatments are hormonal suppression with medical therapy to reduce the size of endometrial implants or laparoscopic surgery (where small incisions are made in the abdomen) to remove visible areas of endometriosis. There is no evidence that hormonal suppression either before or after surgery is associated with a benefit compared with surgery alone.

(Synopsis prepared by Cochrane Menstrual Disorders and Subfertility Group)

Authors' conclusions: 

There is no evidence of benefit associated with post surgical medical therapy and insufficient evidence to determine whether there is a benefit from pre-surgical medical therapy with regard to the outcomes evaluated.

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Background: 

Endometriosis is a common gynaecological condition affecting approximately 10% of women of reproductive age (Ozkan 2008). Common symptoms are dysmenorrhoea, pelvic pain, infertility or a pelvic mass. Diagnosis by laparoscopy or laparotomy enables identification of the location, extent and severity of the disease. Surgery may include removal (excision) or destruction (ablation) of endometriotic tissue, division of adhesions and removal of endometriotic cysts. Laparoscopic excision or ablation of endometriosis has been shown to be effective in the management of pain in mild to moderate endometriosis. Adjunctive medical treatment pre or post-operatively may prolong the symptom-free interval.

Objectives: 

To determine the effectiveness of medical therapies for hormonal suppression before or after surgery for endometriosis for improving painful symptoms, reducing disease recurrence and increasing pregnancy rates.

Search strategy: 

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched Sept 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Sept 2010), MEDLINE (January 1966 to September 2010), EMBASE (January 1985 to September 2010) and reference lists of articles.

Selection criteria: 

Trials were included if they were randomised controlled trials comparing medical therapies for hormonal suppression before or after or before and after, surgery for endometriosis.

Data collection and analysis: 

Data extraction and assessment of risk of bias were performed independently by two authors. Where possible, data were combined using relative risk (RR), standardised mean difference or mean difference and 95% confidence intervals (CI).

Main results: 

Sixteen trials were included. Two trials of pre-surgical medical therapy showed no evidence of benefit compared to surgery alone. There was no evidence of benefit for post-surgical hormonal suppression of endometriosis compared to surgery alone for the outcomes of pain, disease recurrence or pregnancy rates (RR 0.84, 95% CI 0.59 to 1.18). There were no trials identified in the search that compared hormonal suppression of endometriosis before and after surgery with surgery alone. One trial found no evidence that pre-surgical hormonal suppression was different from post-surgical hormonal suppression for the outcome of pain. Another single trial comparing post-surgical medical therapy with both pre and post-surgery found no difference in the outcomes of American Fertility Society (AFS) scores and pregnancy rate.

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