Case studies of recurrent endometriosis: Is oestrogen in combined pills the culprit?

Abstract

Endometriosis is an estrogen dependent inflammatory disease, clinically characterised by dysmenorrhoea, pelvic pain and dyspareunia. It has a high rate of recurrence, between 16% and 52%; the variability likely the result of variable treatment protocols, diagnosis and follow-up. Whilst many aetiological theories have been proposed to explain the development and progression of endometriosis, it is clear that estrogen has a direct role in both the development of extra-uterine endometrial tissue, and also in the excessive production of prostaglandins, via up regulation of COX2 expression. Treatment of endometriosis is classically a combination of surgical ‘see and treat’ modalities, and hormonal options such as the combined oral contraceptive pill (COCP), typically through monocyclic regimes. Three cases are reviewed, in which each woman underwent laparoscopy with treatment of endometriosis, and subsequent achievement of amenorrhoea with COCP. However despite lack of menstruation, each woman returned 2–3 years following their initial surgery, with symptoms of endometriosis such as pelvic pain and dyspareunia. In each case, a second laparoscopy was performed which confirmed endometriosis in each woman. In two of these cases, Mirena was inserted following second laparoscopy, both for contraception and for amenorrhoea, and no recurrence was noted to date. These three cases confirm recurrence of endometriosis following surgical ablation, and despite achievement of amenorrhoea with the COCP for a period of 2–3 years. Based on what is known about the pathogenesis of endometriosis, and the influence of estrogen in the development of the disease process, estrogen containing oral contraceptive pills appear to be a suboptimal choice for treatment. Further studies, including randomised controlled trials comparing different hormonal methods including an estrogen free regime, may direct future best practice for this common and sometimes debilitating condition.