What is different in comparison with ESHRE guidelines below (1)

Medical therapy Before surgery

Facts

Medical therapy for endometriosis suppresses ovarian function. The lack of estrogens inactivates endometriosis lesions (as after menopause)  or the high doses of progestogens will decidualize (as during pregnancy) them.
Subtle and probably other lesions (typical, smaller cystic or some deep)  thus risk to be missed since less visible. Cystic ovarian endometriosis will sometimes decrease slightly in volume. Deep endometriosis will shrink and probably becomes less vascularized.

Potential Benefits

The absence of ovulation and of a corpus luteum can be a surgical advantage.  A corpus luteum indeed bleeds easily when touched during ovarian surgery  with subsequent risks of ovarian damage by coagulation and later adhesion formation.
There should be less confusion between a cystic corpus luteum and  cystic ovarian endometriosis. Practically however, a cystic corpus luteum can persist for more than 6 months under oral contraception.

Adverse effects

Subtle and typical lesions risk to be missed during surgery. Thus the diagnosis is not made and so is the excision.
Cystic ovarian endometriosis . Smaller lesions might be missed. Surgical excision of  is not facilitated by medical therapy.
Deep endometriosis grows irregularly and common sense suggest that excision could be incomplete since extensions are missed.
Appendicular endometriosis risks to be missed.

Conclusions

Medical therapy before
endometriosis surgery

lesions risk to be missed
surgery risks to be incomplete
no surgical advantage
Conclusion: should not be given

Solid evidence that lesions risk to be missed do not exist since it is impossible to demonstrate this in a surgical trial since repeat laparoscopy is ethically unacceptable .
Although there is no evidence that It facilitates surgery some surgeons judge that the decreased vascularisation is more important than the risk to miss some lesions
There is no obvious benefit for outcome of surgery as concluded based on a small trial without the power to detect small differences
Medical treatment before surgery for endometriosis therefore should not be given since it does not have advantages, but it carries the risk of incomplete surgery.

Medical therapy after surgery

Facts

Medical therapy after endometriosis surgery to prevent recurrences. The only available evidence is that medical treatment given for six months after surgical excision of cystic ovarian endometriosis will decrease the recurrence rate during this period
Medical therapy to prevent progression. The arguments are the same as those before surgery. Only for typical lesions there is scanty evidence that the prevalence is less after years of oral contraception (3) . It is unclear whether this is not an artefact by missing lesions.

Potential Benefits

Abolishing menstruation in order to reduce recurrences of endometriosis is a myth based on the Sampson theory.
After complete surgery there are no demonstrated advantages, only speculation.
After incomplete surgery, for whatever reason medical treatment can be given to reduce pain similar to medical treatment in women before surgery.

Risks

Medical therapy risks to be given after incomplete surgery also when this was caused by the lack of skills by the surgeon.

Conclusions

Medical therapy after
endometriosis surgery

If complete surgery
prudent to give OC
If incomplete surgery
repeat surgery if possible
otherwise : medical treatment

If surgery is too difficult for the experience of the surgeon,

the best option for the patient is that no surgery should be done and that the patient should be send for complete surgery elsewhere. This is the model we developed in Oxford UK.
A worse option is incomplete surgery with medical therapy after surgery. Examples of this are an hysterectomy or a bowel resection while leaving the endometriosis in the lateral wall or in the douglas
.

Following complete surgery

although there is no hard evidence that medical therapy is an advantage, it seems prudent, and widely accepted to give medical therapy as oral contraception until the woman wants to become pregnant.
there are no arguments not to give hormone replacement therapy after menopause. It seems wise however not give sequential hormone replacement therapy.
There are no arguments to fear the development of an adenocarcinoma in endometriosis when given estrogens only.
Considering the frequent association of adenomyosis with severe forms of endometriosis, medical therapy should be considered in women with persisting pain.

Which medical therapy should be given before or after surgery?

Medical therapy in
endometriosis surgery

no superiority of any drug

The available medical therapies  comprise those that suppress ovarian function as  Gn-RH and oral contraception and progestagens only in high dose

There is no solid evidence to claim superiority of any of these treatments before or after surgery for endometriosis.

 Content approved and/or updated by

Surgeons : Philippe R. Koninckx , Prof em OBGYN KULeuven Belgium, Univ of Oxford-Hon Consultant, UK, Univ Cattolica, Roma, Moscow State Univ. Gruppo Italo Belga, Villa del Rosario Rome Italy ; Anastasia Ussia Gruppo Italo Belga, Villa del Rosario Rome Italy, Consultant Università Cattolica, Rome, Italy, Arnaud Wattiez,  Prof OBGYN, University of Strassbourg, France and  Dubai,Leila Adamyan, Academician Moscow state University,Moscow, Russia, Roy Mashiach, Vice Chair, Gynecologic Dep Sheba ” Medical Center”, Israël, Camran Nezhat MD FACOG FACS, ENDOMETRIOSIS SPECIALIST . Emile Daraï, Prof. Chef de service de gynécologie obstétrique et médecine de la reproduction, Hôpital Tenon. Bruno van Herendael Em. Prof. Endoscopy, Consultant Ob/Gyn ZNA Stuivenberg Antwerpen, President ISGE, , Horace Roman, Expert Center in the Diagnosis and Multidisciplinary Management of Endometriosis Centre Hospitalier Universitaire “Charles Nicolle”, 76031 Rouen, France, Jasper Verguts, Jessa ziekenhuis Hasselt Belgium , Dan C. MartinRichmond, USA, Rodrigo Fernandes, Minimally Invasive Surgery Specialist & website Pelvic Oncology and Endometriosis, Instituto do Câncer do Estado de São Paulo; Oncology Center - Hospital Alemão Oswaldo Cruz, Oncology Center - Hospital Alemão Oswaldo Cruz Endometriosis Center Hospital Samaritano - São Paulo, Brazil, Hans Brolman, Head of Department VUMC, Amsterdam, The Netherlands. Resad Paya Pasdic Prof MIGS Fellowship Director University of Louisville USA. George A Pistofidis MB BS, FRCOG Director of Gynecological Endoscopy and Reproductive Surgery, White Cross Hospital, Athens, Greece.António Setúbal Director Dept. Ginecologia/CMIG, Head Department of Gynecology/M.I.G.S.Clinical Director of CEI-Centro de Endometriose e Infertilidade ,Lisbon ,Portugal. Ludovico Muzii, Department of Obstetrics and Gynecology, Sapienza University of Rome, Italy. Jörg KecksteinProf - Prim. Univ KABEG Landeskrankenhaus Villach, Zertifiziertes Endometriosezentrum Stufe III, Villach, Austria, Stephan Gordts, Life Expert Centre, Leuven, Belgium, Errico Zupi Prof Univ Tor Vergate, Rome Italy, Michel Canis, Prof & Chairman, Univ Clermond Ferrand, France, , Roberta Corona, Fertility Centre Barbados, Renato Seriaccholi, Prof and chairman Univ Bologna Italy, Jacques Donnez,em prog and chairman Catholic university of Louvain, David Soriano, President ISGE, Director of Center for Multidisciplinary Management of Endometriosis,  Sheba Medical Center, Israel Ron Schonman, Head of endometriosis clinic, Meir Medical Center, Kfar Saba, Israel

Non surgeons : Lone Hummelshoj, www.endometriosis.org

Discussion 

Existing guidelines
reflect published evidence only
Surgical guidelines
reflect all knowledge
and more useful

The ESHRE guidelines (1) for medical therapy before and after surgery for endometriosis are evidence based i.e. based on the published evidence only. These guidelines are biased and not that useful since they do not take into account observational medicine and surgical experience.

The ESHRE Guidelines 1 are published below for comparison
Hormonal therapy before surgery
Guideline : ” Clinicians should not prescribe preoperative hormonal treatment to improve the outcome of surgery for pain in women with endometriosis  (A evidence) ”  There is insufficient evidence from the studies identified to conclude that hormonal suppression in association with surgery for endometriosis is associated with a significant benefit with regard to any of the outcomes identified. There may be a benefit of improvement in AFS scores with the pre-surgical use of medical therapy.(2)
Hormonal therapy after surgery
Guideline :”Clinicians should not prescribe adjunctive hormonal treatment in women with endometriosis for endometriosis-associated pain after surgery, as it  does not improve the outcome of surgery for pain  (A)  GDG concluded that there is no proven benefit of post-operative hormonal therapy (within 6 months after surgery), if this treatment is prescribed with the sole aim of improving the outcome of surgery. The GDG states that there is a role for prevention of recurrence of disease and painful symptoms in women surgically treated for endometriosis. (A)  The choice of intervention depends on patient preferences, costs, availability and side effects. For many interventions that might be considered here, there are limited data. (3)

Reference List

1.     Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D’Hooghe T, De BB et al. ESHRE guideline: management of women with endometriosis. Hum Reprod. 2014;29:400-412.
2.     Yap C, Furness S, Farquhar C. Pre and post operative medical therapy for endometriosis surgery. Cochrane Database Syst Rev. 2004;CD003678.
3.     Vercellini P, Somigliana E, Vigano P, De MS, Barbara G, Fedele L. Post-operative endometriosis recurrence: a plea for prevention based on pathogenetic, epidemiological and clinical evidence. Reprod Biomed Online. 2010;21:259-265.

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