{"paper_id":"42481864-f961-4c49-90c8-7e19b2cd3a70","body_text":"This article has been accepted for publication and undergone full peer review but has not been \nthrough the copyediting, typesetting, pagination and proofreading process, which may lead to \ndifferences between this version and the Version of Record. Please cite this article as doi: \n10.1111/1471-0528.16415\n This article is protected by copyright. All rights reserved\nMR. ERTAN  SARIDOGAN (Orcid ID : 0000-0001-9736-4107)\nArticle type      : Mini commentary\nMini-commentary on BJOG-19-1705.R2: Post-operative hormonal treatment for prevention of \nendometrioma recurrence after ovarian cystectomy: A systematic review and network meta-\nanalysis\nPostoperative medical therapies for the prevention of endometrioma recurrence – do we now \nhave the final answer?\nErtan Saridogan\nUniversity College London Hospital, \nWomen’s Health Division, \n250 Euston Road, \nLondon NW1 2PG \nUnited Kingdom\nEmail: ertan.saridogan@nhs.net\nEndometriosis is often described as a chronic condition. Surgical or medical treatment \napproaches do not always cure it, and recurrence of the disease or its symptoms is common. \nAccepted Article\n\nThis article is protected by copyright. All rights reserved\nMedical treatment is usually used to achieve symptomatic control whilst surgery aims to \neliminate the visible lesions. However, recurrence is frequently seen even after very radical \nsurgery. \nEndometriomas are frequently used for diagnosis and as a marker of recurrence due their easy \nrecognition on imaging. In this issue of BJOG, Wattanayingcharoenchai et al (BJOG 2020 xxxx) \npresent their systematic review and network metaanalysis (NMA) on the efficacy of \npostoperative medical therapies in reducing endometrioma recurrence with some mixed \nmessages. They conclude that evidence from randomised controlled trials (RCTs) do not support \nthe use of postoperative hormonal therapies, whereas data from cohort studies indicate a \nsignificant protective effect of levonorgestrel intrauterine system (LNG-IUS) followed by \ndienogest,  gonadotrophin releasing hormone agonists (GnRHa) + LNG-IUS, continuous and \ncyclical oral contraceptives (OC).  The most effective postoperative therapy (although non-\nsignificant) was GnRHa+LNG-IUS, followed by continuous OC and GnRHa based on RCTs.\nDirect meta-analysis of RCTs in the Wattanayingcharoenchai et al. article indicate an \napproximately 40-50% reduction with OCs but this remained statistically non-significant. This \nfinding is in contrast to an earlier meta-analysis (Vercellini et al. Acta Obstet Gynecol Scand. \n2013;92:8-16) which concluded that the postoperative OC use dramatically reduced the risk of \nendometrioma recurrence and international guidelines that recommend use of hormonal \ncontraceptives for the secondary prevention of endometrioma (Dunselman et al. Hum Reprod. \n2014;29:400-12). So what are we to believe and what should we advise women affected by \nendometriosis to do?\nThere is a wide variation in the design of studies on which metaanalyses and the current NMA \nare based on in terms of inclusion criteria, duration of treatment and definition of recurrence. \nSome studies allocate the participants on the basis of their disease stage without taking the \npreoperative cyst size and bilaterality into account. The definition of a ‘recurrent cyst’ varies \nfrom ‘no definition’ to endometrioma of > 1 cm or >3 cm. These introduce significant \nheterogeneity which potentially compromise the validity of any meta-analysis. Furthermore, \nthere is also a conceptual difference between using medical treatment (e.g. GnRHa) for 3-6 \nAccepted Article\n\nThis article is protected by copyright. All rights reserved\nmonths postoperatively and continuing with therapy (e.g. hormonal contraceptives) in the long \nterm and assessing the recurrence rates at 1-5 years. In fact the ESHRE guideline (Dunselman et \nal.) proposed distinguishing postoperative adjunctive treatment of < 6 months that aims to \nimprove the outcome of surgery and longer treatments with the intention to reduce recurrences \n(secondary prevention). The former may have a significant side effect profile whereas the latter \nhas a good safety record.\nIt is very plausible that suppression of ovulation and reducing/eliminating menstrual flow in the \nlong term would reduce recurrences. The current literature is too heterogeneous and \nfragmented to confirm or refute this. Properly designed large scale studies with the required \npower are still required. The Pre-Empt trial which is currently ongoing in United Kingdom may \ngive some of the answers.  \nDisclosure of interest: None. A completed disclosure of interest form is available to view online \nas supporting information.\nAccepted Article","source_license":"public-domain-us","license_restricted":false}