Post-operative endometriosis recurrence : a plea for prevention based on pathogenetic, epidemiological and clinical evidence

Prevention of the recurrence of post-operative endometriosis is crucial for future fertility. The incidence of disease relapse can be influenced by major demographic changes and by the use of long-term adjuvant medical treatment. Decrease in age at menarche, number of pregnancies and duration of breastfeeding and increase in age at first birth all lead to an increase in the overall number of ovulations and menstruations a woman has within a reproductive lifespan. These changes impact during the decade at highest risk for endometriosis, i.e. between 25 and 35 years of age, and may substantially expand the hiatus between first-line surgical treatment and conception attempt. Several lines of evidence suggest that ovulation inhibition reduces the risk of endometriosis recurrence. After pooling the results of a cohort and a randomized controlled trial on long-term post-operative oral contraceptive use, a recurrent endometrioma developed in 26/250 regular users (10%; 95% CI 7-15%) compared with 46/115 never users (40%; 95% CI 31-50%), with a common OR of 0.16 (95% CI 0.04-0.65). After first-line surgery for endometriosis, women should be invited to seek conception as soon as possible. Alternatively, oral contraceptive use until pregnancy is desired should be considered.