The importance of inducing a state of amenorrhea to reduce the risk of disease recurrence was further underscored by a recent study. Shakiba and colleagues26 reported on the recurrence of endometriosis that required further surgery as long as 7 years after the subjects had been surgically treated for symptomatic endometriosis. The need for subsequent surgery was 8% after hysterectomy and bilateral salpingo-oophorectomy; 12% after hysterectomy alone; and 60% after conservative laparoscopy with preservation of both uterus and ovaries.
Taken together, these data show that, unless the patient is rendered amenorrheic or hypomenorrheic, her risk of recurrence exceeds 50%.
It is important, therefore, to consider conservative surgical management of endometriosis as only the beginning of a lifelong management plan. That plan begins with complete resection of all visible endometriosis and adhesions, resection of endometriomas, and restoration of normal anatomy as much as possible.
When endometriosis cannot be completely resected—as when it involves small bowel or the diaphragm, or is diffusely on the large bowel—we recommend medical suppressive therapy. Our preference is depot leuprolide acetate (Lupron Depot), always with add-back therapy to minimize side effects, which include vasomotor symptoms, vaginal dryness, and bone loss,27 until the patient is significantly asymptomatic, which may take 6 to 9 months.
CASE Concluded, with long-term intervention
You counsel S. D. to remain on a low-dose hormonal OC continuously, until such time that she wants to conceive. If a patient does not want to conceive for at least 5 years, the LNG-IUS may be inserted at surgery to induce hypomenorrhea and reduce the risk of recurrence for the next 5 years.
When hormonal contraceptives are inadequate to control symptoms, adding the aromatase enzyme inhibitor letrozole (Femara), 2.5 mg daily for 6 to 9 months, usually alleviates symptoms with minimal side effects, as long as the patient keeps taking a hormonal contraceptive. Using letrozole without hormonal contraception has not been studied; doing so may lead to formation of ovarian cysts, and is therefore not recommended for managing symptomatic endometriosis.
If the patient wants to become pregnant, encourage her to actively undertake fertility treatment as soon as possible after surgery, thereby minimizing the risk of recurrence of symptoms and disease. The best option may be to employ assisted reproductive technology, but patients cannot always afford it; when that is the case, consider controlled ovarian stimulation and intrauterine insemination.
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