Differentiated approach to the treatment of external genital endometriosis as prevention of recurrence

Abstract

The objective: to evaluate the effectiveness of a differentiated approach in the postoperative management of patients with external genital endometriosis (EGE) to determine the regression of clinical symptoms and reduce the number of recurrences. Materials and methods. 207 patients with different forms of EGE after surgical treatment of the endometriosis foci removal were examined. After the determination of the prevalence of the pathological process (intraoperatively), the subjects were divided into three groups. A1 group (n=67) included women with severe disease who had an optimized approach for postoperative management. A2 group (n=75) included patients with moderate severity of EGE and the traditional treatment approach. B group was a comparison group (n=65) and was formed from patients with severe disease who were traditionally treated.Clinical-anamnestic, laboratory, morphological, immunohistochemical methods, gynecological examination data, ultrasound examination of the pelvic organs were used during the examination of women with EGE; magnetic resonance imaging (MRI) – if necessary. The standard approach included surgical treatment (laparoscopic method), removal of visible endometrioid heterotopias and the medical treatment from the 1st day of the next menstrual cycle after surgery (progestins (dienogest 2 mg) for 6 months or gonadotropin-releasing agonists in the presence of comorbidity of hyperplastic processes for 3-6 months in combination with add-back therapy). In the absence of reproductive plans combined oral contraceptives or intrauterine levonorgestrel-releasing system were used. Patients were observed for 1 month, 1 year after surgery, and then once a year. The optimized approach included surgery (laparoscopy or laparotomy) with the removal of endometrioid heterotopias, use of nonsteroid anti-inflammatory drugs in the postoperative period for 5 days, then dienogest 2 mg for 3-6 months was used by the cases of algomenorrhea and other manifestations of pain. The pathogenetic therapy was started on the 2nd or 3rd day of the postoperative period. Patients were observed for 2 months after surgery, then every 3 months for 1 year. The severity of pain was assessed on the Biberoglu and Behrman (B’n’B) and Numerical Rating Scale (NRS) scales. Recurrence of the disease was diagnosed in the presence of endometrioid heterotopia according to ultrasound examination and/or MRI, as well as the appearance of clinical complaints (pain) in 6 months after their absence.Results. In one year after the first surgery, recurrence of the disease was found in 13.43 % of women in A1 group, 12 % – A2 group and 24.61 % – B group. The average value of pain on the NRS scale in 12 months after treatment was 3.26 points in A1 group, 2.47 – A2 group and 1.59 – B group, on the B’n’B scale - 1.94, 1.61, and 1.40 points, respectively. Conclusions. The applying an optimized approach in the management of patients with severe and moderate external genital endometriosis (more radical surgery, the prescription at once in the postoperative period the hormonal therapy and nonsteroid anti-inflammatory drugs, more frequent observation after surgery) compared with traditional treatment lead to decrease the pain severity on 3.26 points on the Biberoglu and Behrman scale and 1.94 points – the Numerical Rating Scale, and reduce the recurrence rate by 45.4%.