Background: The recurrence of endometriosis after fertility sparing surgery poses a challenge to clinicians. Presently, no treatment option is curative and available medication only changes the hormonal milieu to suppress or delay disease recurrence.
Objective: The aim of this review was to present current literature on recurrent endometriosis including dilemmas in definition, risk factors for recurrence and medical options for the prevention of recurrent endometriosis after surgery.
Methods: A review of literature was done using PubMed, EMBASE and HERDIN, with the following keywords: endometriosis, endometrioma, endometriosis-associated pelvic pain, recurrence of endometriosis. The authors identified reviews, trials and guidelines. The population was limited to reproductive-aged women suspected of having endometriosis.
Results and Discussion: The recurrence rate of endometriosis after conservative surgery ranges from 7.1-56%. The incidence varies according to the criteria used to define recurrence: relapse of pain, physical examination findings, presence of endometrioma on imaging studies, increase in serum CA-125, and intraoperative findings during repeat surgery. The risk factors for disease recurrence include: young age, high body mass index, large endometriomas at diagnosis, severe pre-operative pain, intraoperative findings of extensive adhesions, and positive surgical margins. The identification of patients at high risk for recurrence will enable clinicians to give appropriate post-surgical therapy to prevent recurrence. The choice of pharmacologic agent after conservative surgery includes: combined hormonal contraceptive pills, progestogens, and GnRH agonist. Although no major difference was seen in the effect of available drugs used to relieve endometriosis- associated pain and prevent disease recurrence, differences exist in safety, tolerability and costs.
Conclusion: There is an urgent need to standardize the definition of recurrent endometriosis. Patients should be counselled on the need for long term medical management to delay disease recurrence. A step-wise approach and algorithm in the medical management for the prevention of endometriosis recurrence are proposed.