*These authors contributed equally to this work.
Endometriosis is a common and recurring gynecologic disease which have afflicting females of reproductive age. We investigated the efficacy of long-term, post-operative use of dienogest for ovarian endometrioma.
We studied 203 patients who had undergone laparoscopic or robotic surgery for ovarian endometrioma, and were administrated dienogest 2 mg/day beginning in July of 2013, and continuing. We evaluated side effects of dienogest and ultrasonography was performed every 6 months to detect potential recurrence of endometrioma (2 cm) in these post-surgical patients.
The follow-up observation periods were 30.2±20.9 months from surgery. The mean age was 34.1±7.2 years old. The mean diameter of pre-operative endometrioma was 5.6±3.0 cm2. One hundred eighty-two (89.7%) women received dienogest continuously for 12.0±7.1 months. Of the subjects, 21 (10.3%) patients discontinued dienogest at 2.4±1.0 months. The most common side effect when dienogest was discontinued was abnormal uterine bleeding. The occurrence rate of vaginal bleeding was 15.8%, a number which did not differ significantly in patients with/without post-operative gonadotropin releasing hormone agonist administration. The other side effects were gastrointestinal trouble including constipation, acne, headache, depression, hot flush, weight gain, and edema. However, no serious adverse events or side effects were documented and recurrent endometriomas were diagnosed in 3 patients (1.5%).
The data indicates that dienogest was both tolerable and safe for long-term use as prophylaxis in an effort to obviate the recurrence of ovarian endometrioma post-operatively, as well as potential need for surgical re-intervention.
The pathology called “endometriosis is defined as presence of endometrial tissue (gland and stroma) outside the uterus”. It is the leading cause of disability in women of reproductive age, and is also said to impair the quality of life [
However, recurrent endometrioma is a common dilemma and the condition can become a chronic problem. A pooled analysis of 23 studies estimated recurrence rates of 21.5% at 2 years and 40.0% to 50.0% at 5 years after primary surgery [
Repeated surgery for recurrent endometriomas is associated with evidence of a higher loss of ovarian tissue and is more harmful to the ovarian reserve evaluated by AFC and ovarian volume, if compared with endometriomas operated for the first time [
Due to increased incidence of recurrent endometrioma postoperatively and other surgery related complications, it is necessary to consider the strategy for prophylaxis, or prevention. According to ESHRE revised guidelines in 2014, it has been recommended that all clinicians prescribe, to their post-operative patients, hormone-based contraceptives within the 6-month period following surgery, in an effort to obviate recurrence of the signs and symptoms of recurrent endometrioma [
Although dienogest (2 mg once daily), a fourth-generation progestin, has been implemented and thought to be useful by clinical trial for its long-term use (up to 65 weeks) in the treatment of endometriosis [
Therefore, the present study was conducted to investigate the clinical experience of long-term use of dienogest after surgery for ovarian endometrioma.
This study was conducted retrospectively on 203 patients who underwent laparoscopic or robotic surgery for ovarian endometrioma and subsequent treatment with dienogest (2 mg/day) at the Department of Obstetrics and Gynecology, Ewha Womans University Mokdong Hospital. The surgeries were performed by 4 experienced gynecologic surgeons. The enrolled study population had been prescribed dienogest from July 2013 through February 2016.
All patients were reproductive-aged women with regular menstruation and did not want to get pregnant promptly after surgery. The size of the ovarian endometriomas were varied, and when there were multiple ovarian endometriomas, the mean diameter was measured with the largest and total diameter of cysts by ultrasonography. All ovarian endometriomas seen during surgery were removed and combined pelvic adhesions were dissected. The stage of endometriosis was defined by revised American Society for Reproduction Medicine (rASRM) classification during operation and the diagnosis was confirmed by final histopathology. The patients who were tolerable for gonadotropin releasing hormone (GnRH) agonist were injected it monthly for the time as possible up to 6 months before administration of dienogest.
Baseline characteristics of patients were analyzed and the patients prescribed dienogest (2 mg/day) were seen tri-monthly thereafter, to evaluate for possible side effects. Adverse events were investigated at all visits at the discretion of her doctor during and after treatment of dienogest.
Clinical characteristics of patients were compared between continued dienogest group and discontinued dienogest group. The long-term use was defined treatment for 6 months and more, otherwise, the discontinued group was discriminated a group that stopped before 6 months of starting medication.
Transvaginal or transrectal ultrasound obtained every 6 months, to detect recurrence of endometrioma (≥2 cm). The visualization of round-shaped homogeneous hypoechoic cyst of low-level echoes within the ovary was defined as characteristic ultrasonographic finding of endometrioma.
Statistical analysis was performed using IBM SPSS Statistics version 20 (SPSS Japan Inc., Tokyo, Japan). A Student's
This study was approved by the Institutional Review Board of Ewha Womans University Mokdong Hospital.
The follow-up observation periods were 30.2±20.9 months from surgery for ovarian endometrioma. The mean age was 34.1±7.2 years old (range, 18 to 53 years) and body mass index was 20.8±3.0 kg/m2. One sixty-one (79.3%) of patients were nulliparous women. The mean diameter of pre-operative endometrioma was 5.6±3.0 cm2. Before surgery, serum cancer antigen (CA) 125, CA 19-9, and AMH levels were measured 113.4±428.6 U/mL, 44.1±116.3 U/mL, and 4.4±3.4 ng/mL, respectively. Sixty-nine point five percent of patients had unilocular type of endometrioma and 30.5% were multilocular ovarian cysts. Fifty-three point seven percent were unilateral endometrioma and 46.3% of patients had bilateral cysts. Sixty-nine percent of patients had documented presence of deep infiltrating endometriosis (DIE) according operation finding.
Of the total, 182 (89.7%) of the women received dienogest continuously for 12.0±7.1 months (range, 6 to 35 months) and 21 (10.3%) patients stopped at 2.4±1.0 months (range, 1 to 4 months). Clinical characteristics of patients were then compared between continued group and discontinued group (
Characteristics | Continuous use (n=182) | Discontinuation (n=21) | ||
---|---|---|---|---|
Age (yr) | 33.8±7.1 | 36.9±8.1 | 0.100 | |
BMI (kg/m2) | 20.7±2.9 | 21.4±4.0 | 0.406 | |
Pre-operative blood test | ||||
CA 125 (U/mL) | 120.1±451.3 | 52.8±37.3 | 0.075 | |
CA 19-9 (U/mL) | 46.4±122.7 | 23.9±12.2 | 0.035 | |
AMH (ng/mL) | 4.5±3.4 | 3.6±3.2 | 0.484 | |
Diameter of endometrioma (cm) | 5.6±3.0 | 5.6±2.8 | 0.953 | |
Type of endometrioma | 0.769 | |||
Unilocular | 127 (62.6) | 14 (6.9) | ||
Multilocular | 55 (27.1) | 7 (3.4) | ||
Laterality of endometrioma | 0.029 | |||
Unilateral | 93 (45.8) | 16 (7.9) | ||
Bilateral | 89 (43.8) | 5 (2.5) | ||
Presence of DIE | 0.450 | |||
Absent | 58 (28.6) | 5 (2.4) | ||
Present | 124 (61.1) | 16 (7.9) | ||
Post-operative GnRH agonist (mon) | 3.7±2.5 | 2.8±2.7 | 0.170 |
Values are presented as mean±standard deviation or number (%).
BMI, body mass index; CA, cancer antigen; AMH, anti-Müllerian hormone; DIE, deep infiltrating endometriosis; GnRH, gonadotropin releasing hormone.
In continued dienogest group, the serum CA 19-9 level was significantly higher and the discontinuation rate was significantly lower in patients operated for bilateral endometriomas. The most common side effect, following discontinuation, was abnormal uterine bleeding. The occurrence rate of vaginal bleeding was 15.8%, which did not differ significantly in patients with/without post-operative GnRH agonist administration. One hundred forty-seven patients (72.4%) were injected GnRH agonists for 3.6±2.5 months before dienogest medication.
The other reported side effects included gastrointestinal trouble, constipation, depression, weight gain, edema, hot flashes, headache, and acne (
Side effects | Occurrence rate |
---|---|
Uterine bleeding | 32 (15.8) |
GI trouble/constipation | 6 (3.0) |
Depression | 6 (3.0) |
Weight gain/edema | 5 (2.5) |
Hot flashes | 5 (2.5) |
Headache | 4 (2.0) |
Acne | 1 (0.5) |
Values are presented as number (%).
GI, gastrointestinal.
The follow-up periods between recurrence and last dienogest treatment were 5.7±7.4 months. Three patients (1.5%) were diagnosed with recurrence of endometrioma. These patients had previously undergone surgeries which included laparoscopic ovarian cystectomies for bilateral and multilocular endometriomas with DIE relevant to stage IV by rASRM classification (
Cases | 1 | 2 | 3 | |
---|---|---|---|---|
Sonographic findings of recurrent endometrioma (side/mean diameter, cm) | Right/2.1 | Left/2.0 | Left/3.4 | |
Age (yr) | 34 | 33 | 30 | |
Method of surgery | LOC | LOC | LOC | |
Duration of dienogest (mon) | 18 | 6 | 9 | |
Period between recurrence and last dienogest treatment (mon) | 6 | 6 | 0 | |
Side effects of dienogest | Depression | Weight gain | None | |
Post-operative GnRH agonist (mon) | 3 | 6 | 6 | |
Pre-operative blood test | ||||
CA 125 (U/mL) | 5,489 | 29.6 | 43.7 | |
CA 19-9 (U/mL) | 945.3 | 17.7 | 41 | |
AMH (ng/mL) | 3.88 | 7.48 | 5.7 | |
Diameter of the previous endometrioma (cm) | 14.0 | 7.5 | 9.1 | |
Type of endometriomas | Multilocular | Multilocular | Multilocular | |
Laterality of endometrioma | Bilateral | Bilateral | Bilateral | |
Presence of DIE | Present | Present | Present | |
Stage of rASRM classification | IV | IV | IV |
LOC, laparoscopic ovarian cystectomy; GnRH, gonadotropin releasing hormone; CA, cancer antigen; AMH, anti-Müllerian hormone; DIE, deep infiltrating endometriosis; rASRM, revised American Society for Reproduction Medicine.
Due to increased post-operative recurrence rate of endometrioma and its related complications, a plan for prophylaxis which is to say, secondary prevention, is necessary to improve quality of life and enhance fertility of those suffering from chronic endometriosis. Usually, surgical re-intervention for recurrent endometrioma serves to produce greater loss of ovarian tissue and markedly decreased ovarian reserve [
Although several hormonal therapies are available, no consensus has been established as to which medication is the best option for long-term prevention of recurrence. Though oral contraceptive pills (OCPs) widely used is associated with several side effects, resistance to long-term therapy and has high rate of recurrence (55%) after discontinuation [
Therefore, we need a medication that has minimal side effects, higher compliance and can be used as long-term therapy. One might consider dienogest with its tolerable profile, higher rate of patient compliance, low problematic withdrawal rate and safe for long-term use, it was chosen for the present study [
In the present study, we found that rate of recurrence with dienogest therapy was only 1.5%. Our findings are comparable to the study of Ouchi et al. [
Our 3 patients with recurrence were in young age less than 35 years. Ouchi et al. [
Of the group studied, 89.7% of the women received dienogest continuously for 12.0±7.1 months without complaint of any intolerable symptoms, while 10.3% patients stopped at 2.4±1.0 months. Hence patient's acceptance for dienogest therapy was fairly good. The medical indication for discontinuation can be explained by irregular bleeding (15.8%) and change of planning for conception. Unexpected irregular bleeding was common and troublesome side effect. Constipation (3.0%), depression (3.0%), weight gain (2.5%), hot flashes (2.5%), headache (2.0%), and acne (0.5%) were also noted but were minimal and did not adversely affect the quality of life. Takaesu et al. [
We observed that in continued dienogest group, serum CA 19-9 level was significantly higher and discontinuation rate was significantly lower in patients operated for bilateral endometriomas. Endometriosis is significantly associated with elevated serum CA 125 and CA 19-9 concentrations, and CA 19-9 is increased further in the more advanced stages of disease. Serum CA 125 and CA 19-9 may represent useful biomarkers for the noninvasive diagnosis of endometriosis [
It was also noted that all recurrent endometriomas were bilateral, multilocular, associated with DIE and stage IV by rASRM classification.
The major strength of this study is that follow-up observation period extended over 30.2±20.9 months from surgery till recurrence of ovarian endometrioma. As other previous studies, our study has some limitations. This study was based on the results of small numbers in a single-center. The data from retrospective chart review lacks description of some clinical outcomes and the nature and duration of reported side effects might have been under-estimated. The change of endometriosis-associated pain using a visual analog scale and BMD could not be compared because the results were inadequate, depending on clinicians although long-term treatment with dienogest which seems effective in reducing pain and possible bone loss [
In the present study, we did not divide laparoscopic or robotic surgery. The meticulous surgical technique could provide complete destruction of endometriotic lesions to decrease the recurrence rate as well as preserving the remained ovarian reserve.
We suggest the clinical experience of post-operative long-term use of dienogest, which was safe and tolerable prevention to avoid reoperation for recurrence of ovarian endometrioma. Therefore, therapeutic application of dienogest could be extended for a longer time until the patient desires to become pregnant. Further studies are warranted to establish up to what age long-term dienogest therapy can be given in patients effectively.