Scar endometriosis: Does the medical treatment with LHRH analogue have an effect on its symptomatology and lesions sizes?

Background: Endometriosis defined as the presence of endometrial glands and stroma like tissues outside the uterine cavity. Scar endometriosis (SE) is a rare entity that is difficult to reach diagnosis due to the absence of a uniform clinical presentation with a variety in symptomatology and signs. It is usually a conflict for physicians of different specialists (surgeon, dermatologist, obstetrician, and gynecologist) that delay diagnosis.  Objective Studying the effect of medical treatment with luteinizing hormone-releasing hormone (LHRH) analogue on pain and mass size as a short-term therapy for cases with scar endometriosis that help postponing and reducing dissection size of the surgical intervention.  Patients and Methods: Our study included 14 patients, aged 18 to 40 y, having a previous gynecological or obstetric operation, a painful scar that may increase with menstruation, tender scar and mass palpable under scar diagnosed as scar endometriosis seen in our Mansoura University Hospital (MUH) and Private Clinic over 4.5 years. All patients underwent the following steps to reach a diagnosis ; history taking, examination and lab investigation, operative details and pain (visual analog scale). VAS scores pre-treatment were recorded then patients referred to ultrasound evaluation where any patients with suspicion of scar endometrioma underwent confirmation with FNAC (fine needle aspiration cytology). Patients diagnosed as scar endometriomas received LHRH analogue (Zoladex 3.6mg/month) for 6 months, then VAS score and ultrasound mass size were performed monthly and at the end of the medical treatment period. Patients who had no pain relief at the end of the treatment period were prepared for wide surgical excision with safety margins. Evaluation of the effect of short-term medical treatment as the post-treatment pain VAS score and mass size in comparison to their pretreatment findings were recorded in addition to its effect on surgical intervention postpone.
Results: The study of the 14 patients showed that mean±SD of age was 28.79±4.99, mean±SD of BMI was 26.4 ±1.7, previous operation scar (Umbilical laparoscopic port 2 [14.3%], episiotomy 3 [21.4%] and cesarean scar (CS) scar 9[64.3%]). Cystic mass was 8[57.1%], heterogeneous mass was 6 [42.9%] and mean±SD of US size/cm was 2.42±0.67 (1.6-4.1). Median of pain duration/months was 26.0 (5.0-60.0). Mean±SD of pain VAS score before treatment was 8.0 (6.0-10.0), while after was 2.0 (0-8.0). Median of pain VAS score in cases with cystic lesions before and after treatment was 7.5 (6.0-9.0) and 1.0(0.0-7.0), respectively, with a statistically significant difference. Also, median of pain VAS score in cases with heterogeneous lesions before and after treatment was 9.0 (7.0-10.0) and 7.0 (2.0-8.0), respectively, with a statistically significant difference with more pain relieve in cystic cases than heterogenous one. Patients needed for surgical intervention and not responding to medical treatment were 8 [57.1%]. The cut of the level of US size of cystic lesions was ≤2.65cm, while for heterogeneous lesions was ≤2.20cm with an accuracy of 87.5% and 83.3 %, respectively.
Conclusion: LHRH analogue short-term treatment for scar endometriosis is significantly effective in pain to relieve and decrease mass size in cystic lesions ≤2.65cm and heterogeneous lesions ≤2.05cm that allow surgical intervention postpone and minimize surgical dissection site.