Skip to main content
SpringerLink
Log in

Preventive therapeutic options for postoperative recurrence of ovarian endometrioma: gonadotropin-releasing hormone agonist with or without levonorgestrel intrauterine system insertion

  • General Gynecology
  • Published:
Archives of Gynecology and Obstetrics Aims and scope Submit manuscript

Abstract

Purpose

Here, we compared endometrioma recurrence rates in patients who have undergone a laparoscopic cystectomy and treated with a gonadotropin-releasing hormone agonist (GnRHa) alone or a GnRHa combined with a levonogestrel intrauterine system (LND-IUS).

Methods

We enrolled endometrioma patients who underwent laparoscopic cyst enucleation and divided them into two groups according to postoperative management: GnRHa alone and GnRHa in combination with LND-IUS. We compared preoperative history, perioperative parameters, postoperative endometrioma recurrence, and symptoms between these two groups.

Results

A total of 320 patients were included in the final analysis. With a median 84.6 months of follow-up, we detected significant differences between the two groups with respect to age at surgery (31.6 ± 4.8 vs. 37.6 ± 4.2 years, χ2 = 1.978, p < 0.001), gravida (0 vs. 2, χ2 = 4.391, p < 0.001), parity (0 vs. 1, χ2 = 0.035, p < 0.001), body mass index (21.0 ± 2.5 vs. 21.9 ± 2.4, χ2 = 0.0096, p = 0.009), r-AFS score (48 vs. 64, χ2 = 4.888, p = 0.001), and operation time (60 vs. 75 min, χ2 = 9.119, p = 0.003). Patients treated with both GnRHa and LND-IUS achieved significantly less endometrioma recurrence (23.6 vs. 11.5%, χ2 = 5.202, p = 0.023) and higher rates of pain remission (92.1 vs. 100%, χ2 = 6.511, p = 0.011), while those with GnRHa alone suffered more recurrent and painful symptoms (χ2 = 9.280, p = 0.026). Multivariate analysis using a Cox regression demonstrated that combined GnRHa and LNG-IUS treatment correlated with a decreased endometrioma recurrence rate after laparoscopic cystectomy (RR 0.369, 95% CI 0.182–0.749, p = 0.006).

Conclusions

Combination treatment of GnRHa and LNG-IUS exhibited superior pain relief and recurrence prevention among endometrioma patients after fertility-sparing surgery. Thus, combination treatment is a preferable long-term option for patients without intent for pregnancy in the near future.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Code availability

Not applicable. All the authors gave final approval of the version to be published.

References

  1. Hickey M, Ballard K, Farquhar C (2014) Endometriosis. BMJ 348:g1752. https://doi.org/10.1136/bmj.g1752

    Article  PubMed  Google Scholar 

  2. Shim JY, Laufer MR (2019) Adolescent endometriosis: an update. J Pediatr Adolesc Gynecol. https://doi.org/10.1016/j.jpag.2019.11.011

    Article  PubMed  Google Scholar 

  3. Seo JW, Lee DY, Yoon BK, Choi D (2017) The age-related recurrence of endometrioma after conservative surgery. Eur J Obstet Gynecol Reprod Biol. https://doi.org/10.1016/j.ejogrb.2016.11.015

    Article  PubMed  Google Scholar 

  4. Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D’Hooghe T, De Bie B et al (2014) ESHRE guideline: management of women with endometriosis. Hum Reprod. https://doi.org/10.1093/humrep/det457

    Article  PubMed  Google Scholar 

  5. Ferrero S, Evangelisti G, Barra F (2018) Current and emerging treatment options for endometriosis. Exp Opin Pharmacother 19(10):1109–1125. https://doi.org/10.1080/14656566.2018.1494154

    Article  CAS  Google Scholar 

  6. Geoffron S, Cohen J, Sauvan M, Legendre G, Wattier JM, Darai E et al (2018) 2018 Endometriosis medical treatment: hormonal treatment for the management of pain and endometriotic lesions recurrence CNGOF–HAS endometriosis guidelines. Gynecol Obstet Fertil Senol. 46(3):231–247. https://doi.org/10.1016/j.gofs.2018.02.011

    Article  CAS  PubMed  Google Scholar 

  7. Brown J, Pan A, Hart R (2010) Gonadotrophin-releasing hormone analogues for pain associated with endometriosis. Cochrane Database Syst Rev 8(12):CD0008475

    Google Scholar 

  8. Petta CA, Ferriani RA, Abrao MS, Hassan D, Silva RE, Podgaec S, Bahamondes L et al (2005) Randomized clinical trial of a levonorgestrel-releasing intrauterine system and a depot GnRH analogue for the treatment of chronic pelvic pain in women with endometriosis. Hum Reprod 20(7):1993–1998

    Article  CAS  Google Scholar 

  9. Deng S, Lang J-h, Leng J, Liu Z-f, Liu Z, Sun D-w, Zhu L (2006) Effects of levonorgestrel-releasing intrauterine system on pain and recurrence associated with endometriosis and adenomyosis. Zhonghua Fu Chan Ke Za Zhi. 41(10):664–668

    PubMed  Google Scholar 

  10. Brown J, Farquhar C (2015) An overview of treatments for endometriosis. JAMA 313(3):296–297

    Article  Google Scholar 

  11. Kyoung MK, Chon SJ, Lee JH, Yun BH, Cho S et al (2018) Postoperative levonorgestrel-releasing intrauterine system insertion after gonadotropin-releasing hormone agonist treatment for preventing endometriotic cyst recurrence: a prospective observational study. Reprod Sci 25(1):39–43

    Article  Google Scholar 

  12. Yj C, Tf H, Bs H, Hw T, Yh C, Ph W (2017) Postoperative maintenance levonorgestrel-releasing intrauterine system and endometrioma recurrence: a randomized controlled study. Am J Obstet Gynecol 216(6):15

    Google Scholar 

  13. Jeon SJ, Lee JI, Lee M, Kim HS, Kim JW, Park NH et al (2017) Endometrial polyp surveillance in premenopausal breast cancer patients using tamoxifen. Obstet Gynecol Sci 60(1):26–31. https://doi.org/10.5468/ogs.2017.60.1.26

    Article  PubMed  PubMed Central  Google Scholar 

  14. Gallagher JS, Missmer SA, Hornstein MD, Laufer MR, Gordon CM, DiVasta AD (2018) Long-term effects of gonadotropin-releasing hormone agonists and add-back in adolescent endometriosis. J Pediatr Adolesc Gynecol 31(4):376–381. https://doi.org/10.1016/j.jpag.2018.03.004

    Article  PubMed  PubMed Central  Google Scholar 

  15. Jee BC, Lee JY, Suh CS, Kim SH, Choi YM, Moon SY (2009) Impact of GnRH agonist treatment on recurrence of ovarian endometriomas after conservative laparoscopic surgery. Fertil Steril 91(1):40–45. https://doi.org/10.1016/j.fertnstert.2007.11.027

    Article  CAS  PubMed  Google Scholar 

  16. Yang XH, Ji F, AiLi A, TuerXun H, He Y, Ding Y (2014) Effects of laparoscopic ovarian endometriosis cystectomy combined with postoperative GnRH-a therapy on ovarian reserve, pregnancy, and outcome recurrence. Clin Exp Obstet Gynecol 41(3):272–275

    PubMed  Google Scholar 

  17. Lee DY, Bae DS, Yoon BK, Choi D (2010) Post-operative cyclic oral contraceptive use after gonadotrophin-releasing hormone agonist treatment effectively prevents endometrioma recurrence. Hum Reprod. 25(12):3050–3054. https://doi.org/10.1093/humrep/deq279

    Article  CAS  PubMed  Google Scholar 

  18. Sun TT, Chen SK, Li XY, Zhang JJ, Dai Y, Shi JH et al (2020) Fertility outcomes after laparoscopic cystectomy in infertile patients with stage III–IV endometriosis: a cohort with 6–10 years of follow-up. Adv Ther. https://doi.org/10.1007/s12325-020-01299-w

    Article  PubMed  PubMed Central  Google Scholar 

  19. Porpora MG, Pallante D, Ferro A, Crisafi B, Bellati F, Benedetti PP (2010) Pain and ovarian endometrioma recurrence after laparoscopic treatment of endometriosis: a long-term prospective study. Fertil Steril. 93(3):716–721. https://doi.org/10.1016/j.fertnstert.2008.10.018

    Article  PubMed  Google Scholar 

  20. Tobiume T, Kotani Y, Takaya H, Nakai H, Tsuji I, Suzuki A et al (2016) Determinant factors of postoperative recurrence of endometriosis: difference between endometrioma and pain. Eur J Obstet Gynecol Reprod Biol. 205:54–59. https://doi.org/10.1016/j.ejogrb.2016.07.516

    Article  CAS  PubMed  Google Scholar 

  21. Yucel N, Baskent E, Karamustafaoglu Balci B, Goynumer G (2018) The levonorgestrel-releasing intrauterine system is associated with a reduction in dysmenorrhoea and dyspareunia, a decrease in CA 125 levels, and an increase in quality of life in women with suspected endometriosis. Aust N Z J Obstet Gynaecol 58(5):560–563. https://doi.org/10.1111/ajo.12773

    Article  PubMed  Google Scholar 

  22. Vercellini P, Vigano P, Somigliana E (2005) The role of the levonorgestrel-releasing intrauterine device in the management of symptomatic endometriosis. Curr Opin Obstet Gynecol 17(4):359–365

    Article  Google Scholar 

  23. Abou-Setta AM, Houston B, Al-Inany HG, Farquhar C (2013) Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic endometriosis following surgery. Cochrane Database Syst Rev. 1:CD005072. https://doi.org/10.1002/14651858.CD005072.pub3

    Article  Google Scholar 

  24. Chen YJ, Hsu TF, Huang BS, Tsai HW, Chang YH, Wang PH (2017) Postoperative maintenance levonorgestrel-releasing intrauterine system and endometrioma recurrence: a randomized controlled study. Am J Obstet Gynecol. 216(6):582e1-582e9. https://doi.org/10.1016/j.ajog.2017.02.008

    Article  CAS  Google Scholar 

  25. Kim MK, Chon SJ, Lee JH, Yun BH, Cho S, Choi YS et al (2018) Postoperative levonorgestrel-releasing intrauterine system insertion after gonadotropin-releasing hormone agonist treatment for preventing endometriotic cyst recurrence: a prospective observational study. Reprod Sci 25(1):39–43. https://doi.org/10.1177/1933719117718274

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

We appreciate the staff for their arduous work maintaining the medical records used in the study and the National Natural Science Foundation of China for the project (no. 81501237).

Funding

This work was supported by the National Natural Science Foundation of China (no. 81501237).

Author information

Authors and Affiliations

  1. Department of Obstetrics and Gynecology, Dongcheng District, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Shuaifuyuan No. 1, Beijing, China

    Shi-Yang Zhu, Yu-Shi Wu, Zhi-Yue Gu, Jing Zhang, Shuang-Zheng Jia, Jing-Hua Shi, Yi Dai, Jin-Hua Leng & Xiao-Yan Li

Authors
  1. Shi-Yang Zhu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Yu-Shi Wu
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Zhi-Yue Gu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jing Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Shuang-Zheng Jia
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jing-Hua Shi
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Yi Dai
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Jin-Hua Leng
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Xiao-Yan Li
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

S-YZ and X-YL contributed to protocol development, data analysis, and manuscript writing. Y-SW and JZ collected the data. Z-YG and YD performed data management. S-ZJ analyzed the data. J-HS contributed to data collection or management and data analysis. J-HL is the responsible surgeon.

Corresponding author

Correspondence to Xiao-Yan Li.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This study was approved by the Ethics Committee of Peking Union Medical College Hospital (IRB No. SK730).

Informed consent

This research study was conducted retrospectively according to medical record data obtained during hospitalization. We consulted extensively with the IRB of Peking Union Medical College Hospital (PUMCH) who determined that our study did not require informed consent.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of data and material

The dataset supporting this article is included within the article, and additional data are available from the corresponding author upon request.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zhu, SY., Wu, YS., Gu, ZY. et al. Preventive therapeutic options for postoperative recurrence of ovarian endometrioma: gonadotropin-releasing hormone agonist with or without levonorgestrel intrauterine system insertion. Arch Gynecol Obstet 303, 533–539 (2021). https://doi.org/10.1007/s00404-020-05843-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00404-020-05843-5

Keywords

Search

Navigation