Efficacy of gestagens in the prevention of ovarian endometrioma recurrence after surgical treatment

Ovarianendometriomas occur in 55% of women with endometriosis. Cystectomy is considered the “gold standard” for the surgical treatment of endometriomas but is followed by a high recurrence rate. Hormone therapy with gestagens after surgery can reduce the recurrence rate of the disease. When prescribing gestagens, it is necessary to considerer their efficacy, the benefit-risk ratio of different regimens, and individual preferences of patients. Objective. To study the effect of complex treatment including surgery and postoperative gestagen therapy on the recurrence rate of ovarian endometriomas, pain intensity and quality of life in patients. Patients and methods. This prospective longitudinal comparative study included 70 reproductive-aged women with ovarian endometriomas who underwent surgical treatment. The age of patients ranged between 19 and 47 years (mean age – 34.3 ± 7 years). All patients were randomized into three groups. Group I consisted of 26 patients receiving dydrogesterone 20 mg daily in a prolonged cyclical regimen from day 5 to day 25 of the menstrual cycle. Group II included 21 patients receiving dienogest 2 mg daily in a continuous regimen. Group III (control) consisted of 23 patients who did not receive hormone therapy after surgery. The follow-up period lasted for 12 months. The recurrence rate of endometriomas was assessed using transvaginal ultrasound. Pain intensity was determined by a visual analog scale (VAS). The quality of life of patients was evaluated preoperatively and 12 months after surgery using the Endometriosis Health Profile questionnaire (EHP-5). A questionnaire survey was conducted among patients receiving gestagens to determine their satisfaction with the medication. Results. Intraoperatively, endometriomas were detected in 44.3% of cases in the left ovary (n = 31), in 35.7% (n = 25) in the right ovary, and in 20% (n = 14) in both ovaries. Cystectomy for endometriomas was performed. Among 47 patients receiving gestagens, the recurrence rate was 6.4% (n = 3). Among 23 patients in the control group, recurrence occurred in 34.7% (n = 8) (p = 0.004). Among patients receiving dydrogesterone, there were 2 recurrence cases of endometrioma with a diameter of 3 cm, representing 7.7%. With dienogest therapy, recurrence of endometrioma with a diameter of 4 cm was observed in 1 patient (p = 0.6). Group analysis showed that regardless of the type of gestagen, the recurrence rate was significantly lower in complex treatment compared to the control group. After 12 months of dydrogesterone therapy, VAS pain intensity decreased compared to baseline values – from 7.5 [5, 25; 10] cm to 0.5 [0; 2] cm (p < 0.001), respectively, as well as in the dienogest subgroup – from 7 [5; 10] cm to 0 [0; 2.5] cm (p 0.05). Uterine bleeding occurred in 4 (19%) patients receiving dienogest, while no uterine bleeding occurred with dydrogesterone. A questionnaire survey conducted in subgroups according to the EHP-5 scale revealed an improvement in the quality of life of patients with endometriosis receiving gestagen therapy. Conclusion. The use of gestagens for 12 months after surgical treatment of endometriosis can significantly reduce the recurrence rate of ovarian endometriomas and pain intensity and improve the quality of life of patients without significant differences in efficacy between the dienogest and dyrogesterone groups. Key words: endometrioma, endometriosis, endometrioma recurrence, dydrogesterone, dienogest, gestagens, EHP-5