Advertisement

Surgery versus hormonal therapy for deep endometriosis: is it a choice of the physician?

  • Nicola Berlanda
    Correspondence
    Corresponding author at: Clinica Ostetrica e Ginecologica, Fondazione IRCCS CA’ Granda, Ospedale Maggiore Policlinico, Via della Commenda 12, 20122 Milan, Italy.
    Affiliations
    Department of Obstetrics and Gynecology, Fondazione IRCCS CA’ Granda, Ospedale Maggiore Policlinico, University of Milan, Italy

    Infertility Unit, Fondazione IRCCS CA’ Granda, Ospedale Maggiore Policlinico, University of Milan, Italy
    Search for articles by this author
  • Edgardo Somigliana
    Affiliations
    Infertility Unit, Fondazione IRCCS CA’ Granda, Ospedale Maggiore Policlinico, University of Milan, Italy
    Search for articles by this author
  • Maria Pina Frattaruolo
    Affiliations
    Department of Obstetrics and Gynecology, Fondazione IRCCS CA’ Granda, Ospedale Maggiore Policlinico, University of Milan, Italy

    Infertility Unit, Fondazione IRCCS CA’ Granda, Ospedale Maggiore Policlinico, University of Milan, Italy
    Search for articles by this author
  • Laura Buggio
    Affiliations
    Department of Obstetrics and Gynecology, Fondazione IRCCS CA’ Granda, Ospedale Maggiore Policlinico, University of Milan, Italy

    Infertility Unit, Fondazione IRCCS CA’ Granda, Ospedale Maggiore Policlinico, University of Milan, Italy
    Search for articles by this author
  • Dhouha Dridi
    Affiliations
    Department of Obstetrics and Gynecology, Fondazione IRCCS CA’ Granda, Ospedale Maggiore Policlinico, University of Milan, Italy

    Infertility Unit, Fondazione IRCCS CA’ Granda, Ospedale Maggiore Policlinico, University of Milan, Italy
    Search for articles by this author
  • Paolo Vercellini
    Affiliations
    Department of Obstetrics and Gynecology, Fondazione IRCCS CA’ Granda, Ospedale Maggiore Policlinico, University of Milan, Italy

    Infertility Unit, Fondazione IRCCS CA’ Granda, Ospedale Maggiore Policlinico, University of Milan, Italy
    Search for articles by this author

      Abstract

      Deep endometriosis, occurring approximately in 1% of women of reproductive age, represents the most severe form of endometriosis. It causes severe pain in the vast majority of affected women and it can affect the bowel and the urinary tract. Hormonal treatment of deep endometriosis with progestins, such as norethindrone acetate or dienogest, or estroprogestins is effective in relieving pain in more than 90% of women at one year follow up. Progestins and estroprogestins can be safely administered in the long-term, may be not expensive and are usually well tolerated. Therefore, they should represent the first-line treatment of deep endometriosis associated pain in women not seeking natural conception. However, hormonal treatment is ineffective or not tolerated in about 30% of women, the most common side effects being erratic bleeding, weight gain, decreased libido and headache. Surgical excision of deep endometriosis is mandatory in presence of symptomatic bowel stenosis, ureteral stenosis with secondary hydronephrosis, and when hormonal treatments fail. Surgical treatment is similarly effective as compared to hormonal treatment in relieving dismenorhea, dyspareunia and dyschezia at one year follow up in more than 90% of women with deep endometriosis. Surgical removal of the nodules may require resection of the bowel, ureter or bladder, with possible severe complications such as rectovaginal or ureterovaginal fistula and anastomotic leakage. A thorough counsel with the patient is necessary in order to pursue a therapeutic plan centered not on the endometriotic lesions, but on the patient’s symptoms, priorities and expectations.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      References

        • Weed J.C.
        • Ray J.E.
        Endometriosis of the bowel.
        Obstet Gynecol. 1987; 69: 727-730
        • Ferrero S.
        • Alessandri F.
        • Racca A.
        • Leone Roberti Maggiore U.
        Treatment of pain associated with deep endometriosis: alternatives and evidence.
        Fertil Steril. 2015; 104: 771-792
        • Gabriel B.
        • Nassif J.
        • Trompoukis P.
        • Barata S.
        • Wattiez A.
        Prevalence and management of urinary tract endometriosis: a clinical case series.
        Urology. 2011; 78: 1269-1274
        • Knabben L.
        • Imboden S.
        • Fellmann B.
        • Nirgianakis K.
        • Kuhn A.
        • Mueller M.D.
        Urinary tract endometriosis in patients with deep infiltrating endometriosis: prevalence, symptoms, management, and proposal for a new clinical classification.
        Fertil Steril. 2015; 103: 147-152
        • Koninckx P.R.
        • Ussia A.
        • Adamyan L.
        • Wattiez A.
        • Donnez J.
        Deep endometriosis: definition, diagnosis, and treatment.
        Fertil Steril. 2012; 98: 564-571
        • Fedele L.
        • Berlanda N.
        • Corsi C.
        • Gazzano G.
        • Morini M.
        • Vercellini P.
        Ileocecal endometriosis: clinical and pathogenetic implications of an underdiagnosed condition.
        Fertil Steril. 2014; 101: 750-753
        • Vercellini P.
        • Frontino G.
        • Pietropaolo G.
        • Gattei U.
        • Daguati R.
        • Crosignani P.G.
        Deep endometriosis: definition, pathogenesis, and clinical management.
        J Am Assoc Gynecol Laparosc. 2004; 11: 153-161
        • Fedele L.
        • Bianchi S.
        • Portuese A.
        • Borruto F.
        • Dorta M.
        Transrectal ultrasonography in the assessment of rectovaginal endometriosis.
        Obstet Gynecol. 1998; 91: 444-448
        • Exacoustos C.
        • Malzoni M.
        • Di Giovanni A.
        • et al.
        Ultrasound mapping system for the surgical management of deep infiltrating endometriosis.
        Fertil Steril. 2014; 102: 143-150
        • Guerriero S.
        • Ajossa S.
        • Gerada M.
        • Virgilio B.
        • Angioni S.
        • Melis G.B.
        Diagnostic value of transvaginal ‘tenderness-guided’ ultrasonography for the prediction of location of deep endometriosis.
        Hum Reprod. 2008; 23: 2452-2457
        • Reid S.
        • Lu C.
        • Casikar I.
        • et al.
        Prediction of pouch of Douglas obliteration in women with suspected endometriosis using a new real-time dynamic transvaginal ultrasound technique: the sliding sign.
        Ultrasound Obstet Gynecol. 2013; 41: 685-691
        • Piketty M.
        • Chopin N.
        • Dousset B.
        • et al.
        Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination.
        Hum Reprod. 2009; 24: 602-607
        • Rossi L.
        • Palazzo L.
        • Yazbeck C.
        • et al.
        Can rectal endoscopic sonography be used to predict infiltration depth in patients with deep infiltrating endometriosis of the rectum.
        Ultrasound Obstet Gynecol. 2014; 43: 322-327
        • Alabiso G.
        • Alio L.
        • Arena S.
        • et al.
        How to manage bowel endometriosis: the ETIC approach.
        J Minim Invasive Gynecol. 2015; 22: 517-529
        • Ferrero S.
        • Biscaldi E.
        • Vellone V.G.
        • Venturini P.L.
        • Leone Roberti Maggiore U.
        Computed tomographic colonography versus rectal-water contrast transvaginal ultrasonography in the diagnosis of rectosigmoid endometriosis: a pilot study.
        Ultrasound Obstet Gynecol. 2016; (Epub ahead of print)https://doi.org/10.1002/uog.15905
        • Donnez J.
        • Nisolle M.
        • Squifflet J.
        Ureteral endometriosis: a complication of rectovaginal endometriotic (adenomyotic) nodules.
        Fertil Steril. 2002; 77: 32-37
        • Zupi E.
        • Centini G.
        • Lazzeri L.
        Urinary tract endometriosis: a challenging disease.
        Fertil Steril. 2015; 103: 41-43
        • De Cicco C.
        • Corona R.
        • Schonman R.
        • Mailova K.
        • Ussia A.
        • Koninckx P.
        Bowel resection for deep endometriosis: a systematic review.
        BJOG. 2011; 118: 285-291
        • Donnez J.
        • Squifflet J.
        Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules.
        Hum Reprod. 2010; 25: 1949-1958
        • Nezhat C.
        • Nezhat F.
        • Nezhat C.H.
        • et al.
        Urinary tract endometriosis treated by laparoscopy.
        Fertil Steril. 1996; 66: 920-924
        • Berlanda N.
        • Vercellini P.
        • Carmignani L.
        • Aimi G.
        • Amicarelli F.
        • Fedele L.
        Ureteral and vesical endometriosis. Two different clinical entities sharing the same pathogenesis.
        Obstet Gynecol Surv. 2009; 64: 830-842
        • Schonman R.
        • Dotan Z.
        • Weintraub A.Y.
        • et al.
        Deep endometriosis inflicting the bladder: long-term outcomes of surgical management.
        Arch Gynecol Obstet. 2013; 288: 1323-1328
        • Vercellini P.
        • Crosignani P.G.
        • Somigliana E.
        • Berlanda N.
        • Barbara G.
        • Fedele L.
        Medical treatment for rectovaginal endometriosis: what is the evidence.
        Hum Reprod. 2009; 24: 2504-2514
        • Vercellini P.
        • Giudice L.
        • Evers J.L.
        • Abrao M.S.
        Reducing low-value care in endometriosis between limited evidence and unresolved issues: a proposal.
        Hum Reprod. 2015; 30: 1996-2004
        • Practice Committee of the American Society for Reproductive Medicine
        Treatment of pelvic pain associated with endometriosis: a committee opinion.
        Fertil Steril. 2014; 101: 927-935
        • Vercellini P.
        • Crosignani P.
        • Somigliana E.
        • Viganò P.
        • Frattaruolo M.P.
        • Fedele L.
        ‘Waiting for Godot’: a commonsense approach to the medical treatment of endometriosis.
        Hum Reprod. 2011; 26: 3-13
        • Remorgida V.
        • Abbamonte H.L.
        • Ragni N.
        • Fulcheri E.
        • Ferrero S.
        Letrozole and norethisterone acetate in rectovaginal endometriosis.
        Fertil Steril. 2007; 88: 724-726
        • Hapgood J.P.
        • Africander D.
        • Louw R.
        • Ray R.M.
        • Rohwer J.M.
        Potency of progestogens used in hormonal therapy: toward understanding differential actions.
        J Steroid Biochem Mol Biol. 2013; 142: 39-47
        • Stanczyk F.Z.
        • Hapgood J.P.
        • Winer S.
        • Mishell Jr., D.R.
        Progestogens used in postmenopausal hormone therapy: differences in their pharmacological properties, intracellular actions, and clinical effects.
        Endocr Rev. 2013; 34: 171-208
        • Vercellini P.
        • Pietropaolo G.
        • De Giorgi O.
        • Pasin R.
        • Chiodini A.
        • Crosignani P.G.
        Treatment of symptomatic rectovaginal endometriosis with an estrogen–progestogen combination versus low-dose norethindrone acetate.
        Fertil Steril. 2005; 84: 1375-1387
        • Ferrero S.
        • Camerini G.
        • Ragni N.
        • Venturini P.L.
        • Biscaldi E.
        • Remorgida V.
        Norethisterone acetate in the treatment of colorectal endometriosis: a pilot study.
        Hum Reprod. 2010; 25: 94-100
        • Morotti M.
        • Sozzi F.
        • Remorgida V.
        • Venturini P.L.
        • Ferrero S.
        Dienogest in women with persistent endometriosis-related pelvic pain during norethisterone acetate treatment.
        Eur J Obstet Gynecol Reprod Biol. 2014; 183: 188-192
        • Vercellini P.
        • Bracco B.
        • Mosconi P.
        • et al.
        Norethindrone acetate or dienogest for the treatment of symptomatic endometriosis: a before and after study.
        Fertil Steril. 2016; 105: 734-743
        • Vercellini P.
        • Barbara G.
        • Somigliana E.
        • Bianchi S.
        • Abbiati A.
        • Fedele L.
        Comparison of contraceptive ring and patch for the treatment of symptomatic endometriosis.
        Fertil Steril. 2010; 93: 2150-2161
        • Leone Roberti Maggiore U.
        • Remorgida V.
        • Scala C.
        • Tafi E.
        • Venturini P.L.
        • Ferrero S.
        Desogestrel-only contraceptive pill versus sequential contraceptive vaginal ring in the treatment of rectovaginal endometriosis infiltrating the rectum: a prospective open-label comparative study.
        Acta Obstet Gynecol Scand. 2014; 93: 239-247
        • Fedele L.
        • Bianchi S.
        • Zanconato G.
        • Portuese A.
        • Raffaelli R.
        Use of a levonorgestrel-releasing intrauterine device in the treatment of rectovaginal endometriosis.
        Fertil Steril. 2001; 75: 485-488
        • Fedele L.
        • Bianchi S.
        • Montefusco S.
        • Frontino G.
        • Carmignani L.
        A gonadotropin-releasing hormone agonist versus a continuous oral contraceptive pill in the treatment of bladder endometriosis.
        Fertil Steril. 2008; 90: 183-184
        • Angioni S.
        • Nappi L.
        • Pontis A.
        • et al.
        Dienogest. A possible conservative approach in bladder endometriosis. Results of a pilot study.
        Gynecol Endocrinol. 2015; 31: 406-408
        • Vercellini P.
        • Somigliana E.
        • Consonni D.
        • Frattaruolo M.P.
        • De Giorgi O.
        • Fedele L.
        Surgical versus medical treatment for endometriosis-associated severe deep dyspareunia: I. Effect on pain during intercourse and patient satisfaction.
        Hum Reprod. 2012; 27: 3450-3459
        • Berlanda N.
        • Somigliana E.
        • Viganò P.
        • Vercellini P.
        Safety of medical treatments for endometriosis.
        Expert Opin Drug Saf. 2016; 15: 21-30
        • Fedele L.
        • Bianchi S.
        • Zanconato G.
        • Raffaelli R.
        • Berlanda N.
        Is rectovaginal endometriosis a progressive disease?.
        Am J Obstet Gynecol. 2004; 191: 1539-1542
        • Vercellini P.
        Introduction management of endometriosis: moving toward a problem-oriented and patient-centered approach.
        Fertil Steril. 2015; 104: 761-763
        • Abrão M.S.
        • Petraglia F.
        • Falcone T.
        • Keckstein J.
        • Osuga Y.
        • Chapron C.
        Deep endometriosis infiltrating the recto-sigmoid: critical factors to consider before management.
        Hum Reprod Update. 2015; 21: 329-339
        • Somigliana E.
        • Garcia-Velasco J.A.
        Treatment of infertility associated with deep endometriosis: definition of therapeutic balances.
        Fertil Steril. 2015; 104: 764-770
        • Sallam H.N.
        • Garcia-Velasco J.A.
        • Dias S.
        • Arici A.
        Long-term pituitary downregulation before in vitro fertilization (IVF) for women with endometriosis.
        Cochrane Database Syst Rev. 2006; (CD0 04635)
        • De Ziegler D.
        • Gayet V.
        • Aubriot F.X.
        • et al.
        Use of oral contraceptives in women with endometriosis before assisted reproduction treatment improves outcomes.
        Fertil Steril. 2010; 94: 2796-2799
        • Fedele L.
        • Bianchi S.
        • Zanconato G.
        • Bettoni G.
        • Gotsch F.
        Long-term follow-up after conservative surgery for rectovaginal endometriosis.
        Am J Obstet Gynecol. 2004; 190: 1020-1024