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Evidence summaries

Oral Contraceptives in the Treatment of Endometriosis

Combined hormonal contraceptives appear to be effective for pain associated with endometriosis compared with placebo. Level of evidence: "B"

A Cochrane review 1 [Abstract] included 5 trials, of which 3 trials including a total of 404 subjects provided data for analysis. Compared with placebo, combined oral contraceptives (COC) improved self-reported pain: in dysmenorrhoea verbal rating scale (scale 0 to 3) mean difference (MD) -1.30 points, 95% CI -1.84 to -0.76; 1 RCT, n=96; in dysmenorrhoea visual analogue scale MD -23.68 points, 95% CI -28.75 to -18.62; 2 RCTs, n= 327, and a reduction in menstrual pain from baseline to the end of treatment (MD 2.10 points, 95% CI 1.38 to 2.82; 1 RCT, n=169). One underpowered unblinded trial compared COC with goserelin. At the end of treatment, the women in the goserelin group were amenorrhoeic. At 6 months' follow-up, there was no clear difference between the groups.

A systematic review 2 included 9 RCTs. The combined hormonal contraceptives (CHC) significantly reduced dysmenorrhea, pelvic pain, and dyspareunia compared with placebo, comparator or no treatment from baseline in most studies; continuous administration seemed to be more useful than cyclic administration. The effectiveness of CHC for pain reduction was similar to or less than that of oral progestins and GnRH agonists.

A systematic review 3 assessed the effectiveness of hormonal contraception on endometriosis-related pain (dysmenorrhoea, pelvic pain and dyspareunia), quality of life (QoL) and postoperative rate of disease recurrence compared with placebo or comparator therapies. CHC and progestin-only contraceptive (POC) treatments were associated with clinically significant reductions in dysmenorrhoea, often accompanied by reductions in non-cyclical pelvic pain and dyspareunia and an improvement in QoL. Only 3 studies found that the postoperative use of COCs (ethinylestradiol [EE]/norethisterone acetate, EE/desogestrel and EE/gestodene) reduced the risk of disease recurrence. There was no evidence that POC reduced the risk of disease recurrence.

Comment: The quality of evidence is downgraded by study limitations (unclear allocation concealment and blinding).

    References

    • Brown J, Crawford TJ, Datta S et al. Oral contraceptives for pain associated with endometriosis. Cochrane Database Syst Rev 2018;(5):CD001019. [PubMed]
    • Jensen JT, Schlaff W, Gordon K. Use of combined hormonal contraceptives for the treatment of endometriosis-related pain: a systematic review of the evidence. Fertil Steril 2018;110(1):137-152.e1. [PubMed]
    • Grandi G, Barra F, Ferrero S, et al. Hormonal contraception in women with endometriosis: a systematic review. Eur J Contracept Reprod Health Care 2019;24(1):61-70 [PubMed]

Primary/Secondary Keywords