Long-term oral contraceptive pills and postoperative pain management after laparoscopic excision of ovarian endometrioma: a randomized controlled trial

Literature Review Article

Long-term oral contraceptive pills and postoperative pain management after laparoscopic excision of ovarian endometrioma: a randomized controlled trial. Fertil Steril. 2010 Jul;94(2):464-71. Epub 2009 May 13. 

Review
Paul C. Lin, M.D.
 

The importance of this study stems from the fact that there are no well-designed studies looking at the use of oral contraceptive pills as a postoperative adjuvant therapy after excision of endometriosis. This study looked at 311 subjects who underwent laparoscopic excision of endometriomas (or at minimum stage III by AFS criteria), not attempting to get pregnant at the time of surgery, and suffering from moderate to severe pain. Subjects were randomly assigned in a non-blinded fashion to no treatment, continuous monophasic combined OC, or cyclic monophasic combined OC. All groups were followed for 24 months. Key endpoint variables were dysmenorrhea, dyspareunia and chronic pelvic pain, and were assessed based on the standard 10-point visual analogue scale. Baseline characteristics were equivalent between all three groups.

Dysmenorrhea recurrence rates were reduced in the continuous users versus the cyclic and non-users. Cyclic users showed a decreased recurrence rate, but it took longer to achieve that difference when compared with non-users. Recurrence rates were not different amongst all study groups for chronic pelvic pain and dyspareunia. Cumulative pain-free rate was also analyzed, and demonstrated that continuous use over both cyclic and non-users after 18 months postoperatively for dysmenorrhea. No difference was seen for dyspareunia and chronic pelvic pain variables.

This study shows in a randomized, non-blinded fashion, an overall symptomatic benefit to patients of continuous administration of oral contraceptive when given as an adjuvant postoperative therapy. No intent to treat analysis was done, but drop-out rates were fairly equal between study groups. Placebo effect, given its non-blinded designed, was also acknowledged as a confounding variable. Authors theorized that the benefit seen with continuous administration was reducing the frequency and severity of the menstrual flow and hence, the dysmenorrhea associated with such events.

Comments
Daniel B. Williams, M.D.
 

This study validates the clinical effectiveness of oral contraceptive as a post operative therapy following laparoscopic endometrioma excision.  While both cyclic and continuous users had relief of dysmenorrhea,  continuous users had more and rapid symptom relief.  For patients with other symptoms (i.e.  dysparuenia, chronic pelvic pain), additional treatment may be indicated. The treatment also appears to be well tolerated, as this study evaluated patients for 24 months with similar drop-out rates between groups. It would appear that this treatment would be most effective in patients whose primary symptom is dysmenorrhea.

The above review and commentary on this article were written by SRS members. Publication of these summaries does not reflect endorsement of any particular procedure or treatment. Views expressed in these summaries do not necessarily reflect the views of SRS or ASRM.

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