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Endometriosis · Surgical Treatment

Peritoneal defects and the development of endometriosis in relation to the timing of endoscopic surgery during the menstrual cycle

Schweppe KW, Ring D

Published October 10, 2002 Fertility and Sterility, 78(4), 763-766
DOI 10.1016/s0015-0282(02)03431-3 PMID 12372453
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RRM Academy Synopsis

Stage I-II endometriosis recurred twice as often after luteal surgery

Minimal-to-mild endometriosis came back about twice as often after luteal-phase surgery, a chart review at one hospital found. Of 220 women, about 15 out of 100 operated on days 22 to 28 had biopsy-proven recurrence within 2 years. About 8 out of 100 had it after follicular-phase surgery. About 7 out of 100 had it after periovulatory-phase surgery.

Key Findings

  • The total recurrence rate after 2 years was 9.6% among the 220 women.
  • Biopsy-confirmed recurrence at 24 months: 10 of 67 women (14.9%) in the luteal phase, 5 of 62 (8.1%) in the follicular phase, and 6 of 91 (6.6%) in the periovulatory phase.
  • The luteal group had a significantly higher recurrence rate as early as 6 months and throughout the 2 years. The follicular and periovulatory groups did not differ.
  • Macroscopy and microscopy agreed in 89% of laparoscopic findings overall: 91% in the luteal phase, 89% in the follicular phase and 87% in the periovulatory phase.
  • With three exceptions, all visual recurrences occurred as peritoneal disease, in the original sites and in additional peritoneal sites.

Interpretation

The study is a retrospective chart review from one hospital. Surgery timing followed operating capacity and patient wishes, so cycle phase was not assigned. The authors hypothesize that unhealed surgical wounds at menstruation can facilitate attachment of shed endometrial tissue. They describe peritoneal trauma as an additive factor that facilitates implantation. The paper does not measure wound healing directly. Only women with stage I or II disease and no medical treatment were included, and 38 of 258 eligible women were lost to follow-up. The result is an association within one clinic's records.

RRM Context

The authors advise scheduling endoscopic surgery for peritoneal endometriosis in the first half of the cycle. Restorative reproductive medicine treats the cycle as clinical information. In this one-clinic review of stage I and II disease, cycle phase at surgery was associated with return of disease. The study placed each woman in a phase using her last period date, hormone blood tests before surgery and her next period. The authors call the overall 9.6% rate in accordance with the literature.

Our editorial summary of this paper, not the article's abstract.

Abstract

Objective

In vitro studies demonstrated that implantation on membranes (peritoneum, amniotic membranes) can take place if there are defects on the surface of the membranes. If these mechanisms play a role for the development of endometriosis in vivo, then patients with surgical treatment of peritoneal endometriosis in the luteal phase must have a high recurrence rate.

Design

Retrospective analysis of operation charts and follow-up data.

Setting

Department of gynecology, in a hospital-based endometriosis treatment center.

Patients

Two hundred twenty premenopausal women.

Interventions

Laparoscopic treatment for peritoneal endometriosis, stage I and II by revised American Society for Reproductive Medicine guidelines.

Main Outcome Measures

During the follow-up period of 2 years, symptoms and gynecological and sonographic findings were documented. In case of suspected recurrence a repeat laparoscopy with biopsy was performed to prove the recurrent endometriosis macroscopically and histologically.

Results

The total recurrence rate after 2 years was 9.6%. The recurrence rate of group III (15%) was twice as high as those of group I (7%) and group II (8%), as indicated by subjective complaints, clinical findings, macroscopy, and histology; no differences were found between groups I and II.

Conclusions

Endoscopic surgery for the treatment of peritoneal endometriosis should not be performed in the luteal phase.

Topics

By this author

Hormonal Agents · Progesterone and Progestins

Classification and pharmacology of progestins

Schindler AE et al., 2003 Maturitas

Besides the natural progestin, progesterone, there are different classes of progestins, such as retroprogesterone (i.e. dydrogesterone), progesterone derivatives (i.e. medrogestone) 17alpha-hydroxyprogesterone derivatives (i.e. chlormadinone acetate, cyproterone acetate, medroxyprogesterone acetate, megestrol acetate), 19-norprogesterone derivatives (i.e. nomegestrol, promegestone, trimegestone, nesterone), 19-nortestosterone derivatives norethisterone (NET), lynestrenol, levonorgestrel, desogestrel, gestodene, norgestimate, dienogest) and spironolactone derivatives (i.e. drospirenone). Some of the synthetic progestins are prodrugs, which need to be metabolized to become active compounds. Besides the progestogenic effect, which is in common for all progestins, there is a wide range of biological effects, which are different for the various progestins and have to be taken into account, when medical treatment is considered.

Related research

Fertility and Outcomes · Conception After Excision

Reproductive capacity and recurrence of disease after surgery for moderate and severe endometriosis - a retrospective single center analysis

Schippert C et al., 2020 BMC Women's Health Free full text on PubMed Central

Background Endometriosis can be associated with considerable pain and sterility. After surgical excision of moderate or severe endometriosis lesions, the rate of recurrence reaches up to 67%. The objective of this retrospective study was to establish the recurrence and pregnancy rates following surgical resection of stage III/IV endometriosis lesions. Indications for operation were endometriosis symptoms, sonographic findings and/or infertility. Methods A total of 456 patients who underwent stage III/IV endometriosis surgery between 2004 and 2014 were sent a questionnaire relating to their postoperative medical treatment, pregnancies, relief of symptoms and recurrence. Responses of 206 patients (45.2%) and their clinical data were analysed for this study. Results A total of 66.5% ( N = 137) of patients had stage III disease, and 33.5% ( N = 69) had stage IV disease. The average age was 37 years (17–59). A total of 63.1% ( N = 130) of surgeries were performed by laparoscopy, 21.8% ( N = 45) were performed by laparotomy and 15% ( N = 31) were performed by conversion. Complete resection of endometriosis lesions was achieved in 90.8% of patients ( N = 187). After surgery, 48.5% ( N = 100) of the women did not receive hormonal treatment; the main reason was the desire for children in 53%. Complete or partial relief in complaints was achieved in 93.2% ( N = 192). The rate of recurrence was 21.8% ( N = 45). The statistically significant factors that was associated with a higher risk to develop recurrence was an age < 35 ( p < 0.005). After surgery, 65.8% (79/120) of patients who wished to have children became pregnant. There was a statistically significant association among a higher postoperative pregnancy rate and age < 35 ( p < 0.003) in multivariate logistic regression analysis and laparoscopic surgical access in univariate logistic regression analysis ( p < 0.01). Conclusion We assessed the high percentage of complete or partial relief of symptoms of 93.2%, the high postoperative pregnancy rate of 65.8% and the low rate of recurrence of 21.8% compared to international literature to be very encouraging for women suffering from moderate and severe endometriosis. Though laparoscopy is considered the ‘gold standard’of endometriosis surgery, laparotomy still may be indicated in patients with extensive endometriosis especially to preserve reproductive function.

Surgical Treatment · Recurrence After Surgery

The Long-term Rate of Repeat Surgery After Optimal Excision Surgery of Endometriosis at a Single Tertiary Referral Center

Yeung P et al., 2025 Acta Scientific Women's Health Free to read

The primary purpose of this prospective cohort study was to determine if treating endometriosis with optimal excision surgery leads to lower rates of repeat surgery as compared to historical rates of repeat surgery by ablation. A secondary outcome was to examine whether the use of hormonal suppression differed before surgery, depending on the stage of endometriosis found at surgery. Optimal excision was defined as completely excising all areas of abnormal peritoneum, wherever found in the pelvis, having looked systematically with near contact laparoscopy. All surgeries were performed by a single surgeon specializing in optimal excision at a tertiary referral center. The rate of repeat surgery after optimal excision surgery for endometriosis was remarkably low (2.5%, 15/620) as compared to historical rates of repeat surgery by ablation. Additionally, the lack of significant evidence between hormonal suppression use and progression of stage of endometriosis provides implicit evidence that hormonal suppression does not prevent progression of the disease. Further controlled studies are needed to verify these findings.

Surgical Treatment · Recurrence After Surgery

Recurrence of endometriosis: risk factors, mechanisms and biomarkers

Bozdag G, 2015 Women's health (London, England)

While the incidence of endometriosis is up to 40-60% in women with severe dysmenorrhea/chronic pelvic pain, patients with subfertility carries a risk up to 20-30%. In symptomatic patients, although medical therapy is preferred in women with endometriosis, surgery might be needed in nonresponders or patients with an endometrioma. Following the surgery, recurrence of the disease and/or symptoms might be still noticed which will progressively increase as times goes by. Nevertheless, some risk factors have been identified for the risk of recurrence that decreases the success of the procedure. Those risk factors might be classified as patient-disease related and surgery-associated variables. Herein, we will address about the management of endometriosis regarding the risk factors for relapse, mechanisms of recurrence and potential biomarkers to predict the event.

Surgical Treatment · Recurrence After Surgery

Conservative laparoscopic excision of endometriosis by sharp dissection: life table analysis of reoperation and persistent or recurrent disease

Redwine DB, 1991 Fertility and sterility

To determine the long-term outcome after laparoscopic excision of endometriosis. This longitudinal unmatched study evaluated surgical outcome using follow-up questionnaires and evaluation of reoperations with results presented in life table format. Surgery was performed by a private practitioner at a referral center. All 359 patients undergoing laparoscopic excision of endometriosis between December 12, 1980, and March 31, 1990, were studied. Endometriosis, including deeply invasive disease, was completely excised laparoscopically using 3-mm scissors and graspers. Adjunctive medical therapy was not used. Extent of disease present at reoperation and quarterly rates of reoperation and recurrent/persistent disease are used as indicators of efficacy of surgery. Interval rates of reoperation and recurrence/persistence of disease and extent or invasiveness of disease when found at reoperation did not increase with the passage of time after surgery. The maximum cumulative rate of recurrent or persistent disease was 19%, achieved in the 5th postoperative year. Laparoscopic excision of endometriosis results in a low rate of minimal persistent/recurrent disease. The natural history of endometriosis after surgery suggests a rather static nature of the disease.

Endometriosis › Surgical Treatment › Recurrence After Surgery · Reproductive Surgery › Laparoscopy › Technique · General Gynecology › Clinical Practice › Practice Patterns
Dieter Ring
D Ring
PMID 12372453 12372453 DOI 10.1016/s0015-0282(02)03431-3 10.1016/s0015-0282(02)03431-3 Schweppe et al. 2002, Schweppe 2002

Cite this article

Schweppe, K., & Ring, D. (2002). Peritoneal defects and the development of endometriosis in relation to the timing of endoscopic surgery during the menstrual cycle. Fertility and sterility, 78(4), 763-766. https://doi.org/10.1016/s0015-0282(02)03431-3

Keywords

Biopsy, Endometriosis/pathology/surgery, Female, Follicular Phase, Humans, Laparoscopy, Luteal Phase, Menstrual Cycle, Ovulation, Peritoneal Diseases/pathology/surgery, Premenopause, Recurrence, Reoperation, Retrospective Studies, Time Factors, Treatment Outcome

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