Hormone therapy for women with endometriosis and surgical menopause

Endometriosis is known to result in variable severity of symptoms. For some women bilateral removal of the ovaries (oophorectomy) with or without an hysterectomy may be required to manage symptoms. This brings women into premature menopause. It is thought that hormone replacement therapy may enhance the recurrence of the disease due to its effect on the remaining endometriotic deposits in the pelvis. Only two small randomised controlled were identified in the literature that looked at this problem. Further research is required to clarify the effect of different hormone replacement therapy types on the recurrence of the disease and the associated pain including during sex.

Authors' conclusions: 

Hormone replacement therapy for women with endometriosis in post-surgical menopause could result in pain and disease recurrence. However, the evidence in the literature is not strong enough to suggest depriving severely symptomatic patients from this treatment. There is a need for more randomised controlled studies.

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Background: 

Endometriosis is characterized by the presence of ectopic endometrial tissue that might lead to many distressing and debilitating symptoms. Despite available studies supporting standard hormone therapy for women with endometriosis and post-surgical menopause, there is still a concern that estrogens may induce a recurrence of the disease and its symptoms.

Objectives: 

This review aimed to look at pain and disease recurrence in women with endometriosis who used hormone therapy for post-surgical menopause.

Search strategy: 

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialized Register (March 2008), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 3), MEDLINE (1966 to March 2008), EMBASE (1980 to March 2008), and references lists of articles. Relevant journals and conference proceedings were handsearched.

Selection criteria: 

Randomized controlled trials studying hormone therapy for women with endometriosis in post-surgical menopause.

Data collection and analysis: 

Review authors assessed the eligibility of trials and their quality.

Main results: 

Two studies fulfilled our inclusion criteria. One trial compared the nonstop transdermal application of 17β-estradiol (0.05 mg/day) combined with cyclic medroxy progesterone acetate (10 mg per day) for 12 days per month in women with a conserved uterus with nonstop tibolone (2.5 mg/day). The second trial used sequential administration of estrogens and progesterone with two 22 cm2 patches applied weekly to produce a controlled release of 0.05 mg/day. Micronized progesterone was administered orally (200 mg/day) for 14 days with a 16-day interval free of treatment.  

Pain and dyspareunia
The first trial reported recurrence of pain in the estrogen and progesterone arm in 4/10 of women compared with 1/11 in the tibilone arm. In the latter, 4/115 women reported recurrence of pain in the treatment group compared with 0/57 patients in the no-treatment arm. Neither finding was statistically different.

Confirmed recurrence or exacerbation of endometriosis
This outcome was not reported in the first trial. The second found that 2/115 of the treatment group developed recurrence of endometriosis with no recurrence reported in the no-treatment group. This was not statistically significant. No woman was re-operated on in the no-treatment group compared with 2/115 in the treatment group.

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