Good News for Women with Endometriosis!

Abstract

I read with great interest the study of Seracchioli et al. and I would like to start by warmly congratulating the authors. In fact as a gynecologist involved in the management of endometriosis I have always been aware that postoperative long-term suppression of menses ought to follow the surgical procedure to reduce recurrence. Today we have LE-1 data supporting the usefulness of postoperative long-term medical treatment and this is very good news for our patients! However regarding the trial there are some remarks that might be made. First the authors stated that they performed an intention-to-treat analysis; however this is not true because several women dropped out after the randomization procedure (n 1/4 10 6 and 6 women in each group representing almost 10% of the sample). I would like to highlight that the principle of intention to treat is avoiding any secondary exclusion to guarantee the perfect comparability of the groups due to the randomization procedure. Second the study showed that the rate of recurrence in nonusers is threefold higher than in continuous users of the contraceptive pill. In fact I think that the difference is even higher because it is very likely that more than six nonusers actually took the treatment because of recurrent pain. Unfortunately the study was not double blinded and nonusers were aware that they were not taking a hormonal treatment that was potentially efficient in preventing recurrences. As I daily encounter women presenting with endometriosis I cannot imagine that nonuser patients with recurrence of cyclic pain will accept relieving it only with anti-inflammatory drugs for several months namely until the end of the study. Consequently it would be expected that several women presenting with recurrent pain and taking a hormonal treatment despite their inclusion in the nonusers arm of the trial would have been likely to develop an endometrioma in the absence of such treatment. Furthermore how did the authors make sure nonusers were using onlynonhormonal contraceptive methods during the 2 years of the study? In my opinion this study is one of the most important trials I have read in the last few years in the field of endometriosis. It clearly showed that surgery alone should no longer be proposed to patients who do not intend to get pregnant immediately after the surgical procedure and that postoperative medical treatment is useful when it is administered for the long term. I am looking forward to reading the next systematic review concerning postoperative treatment because the study of Seracchioli et al. will probably move the superior limit of the 95% confidence interval of the odds ratio below the value 1 and will definitively prove that the usefulness of the postoperative treatment should no longer be debated. (full-text)