Effect of postoperative hormonal therapy on pain following endometriosis surgery: a retrospective cohort study

Endometriosis is heterogeneous, and evidence for individualised postoperative management is limited. We assessed whether postoperative hormonal therapy exposure is associated with one-year changes in pain domains after first-time endometriosis surgery and explored factors related to treatment allocation. Retrospective cohort study (Erlangen, 09/2019–06/2024) of premenopausal women (18–45 years) undergoing first minimally invasive surgery for endometriosis-associated pain with one-year follow-up. Patients were classified into four hormonal therapy (HT) patterns based on baseline and follow-up status: HT none (n = 73), HT initiation (n = 57), HT discontinuation (n = 21), and HT continuation (n = 38). For each pain domain, adjusted analysis of covariance (ANCOVA) models estimated one-year follow-up Numeric Rating Scale (NRS) differences, and therapy-group effects were tested using robust Wald omnibus tests with Holm multiplicity adjustment across domains, and post-hoc contrasts were Holm-adjusted within domains and interpreted only for domains with significant omnibus tests. HT-group membership was analysed using multinomial logistic regression. After multiplicity adjustment across domains, therapy-group differences were observed only for dysmenorrhoea/pelvic pain (p < 0.001). Within this domain, only HT initiation was associated with lower one-year follow-up scores versus HT none (adjusted difference −2.39 NRS points, 95% confidence interval (CI) −3.58 to −1.21; p < 0.001), whereas other contrasts were not significant after within-domain multiplicity correction. No domain-level evidence of between-group differences was found for dyspareunia, dysuria, or dyschezia. Younger age was associated with HT initiation (odds ratio (OR) 0.92, 95% CI 0.86–0.98; p = 0.012) and continuation (OR 0.82, 95% CI 0.74–0.91; p < 0.001). HT initiation was associated with lower one-year dysmenorrhoea/pelvic pain scores, while other domains showed no consistent differences. Younger patients were more likely to initiate or continue hormonal therapy, suggesting non-random allocation. Given the observational design and potential residual confounding, findings are hypothesis-generating and support symptom-profile-guided postoperative management; prospective studies with standardised regimens and domain-specific outcomes are needed. Endometriosis can cause different kinds of pain. This may include period-related pain in the lower abdomen (pelvic pain), pain during sex, pain when passing urine, and pain during bowel movements. Surgery can remove visible endometriosis lesions. Many women are advised to use hormone treatment, but it is not clear whether this helps all types of pain in the same way. We looked at information from women aged 18–45 years who had their first keyhole surgery for endometriosis-related pain and completed a follow-up questionnaire one year later at our specialist centre in Erlangen, Germany. We compared four groups: women who did not use hormone treatment at all, women who started hormone treatment after surgery, women who stopped hormone treatment by the one-year follow-up, and women who used hormone treatment both before surgery and at follow-up. Most women reported that their symptoms improved one year after surgery. When we compared the groups, the clearest difference was for period-related lower abdominal pain: women who started hormone treatment after surgery improved more than women who stopped hormone treatment or did not use it. For pain during sex, urination, or bowel movements, we did not see the same pattern. Younger women were more likely to start or continue hormone treatment. Because this study looked back at existing records rather than assigning treatments, we cannot prove that hormone treatment caused the improvement. Overall, hormone treatment after surgery may be most helpful for period-related pelvic pain, while other pain symptoms may need additional or different approaches.