by Robert B. Albee, Jr MD FACOG ACGE FOUNDER
Let me begin by explaining what I mean by the term 'post-op ovarian suppression'. When I say this, I am talking about using a medication to make the ovary inactive for a period of time immediately after surgery. In most cases a birth control pill is used because it is the least expensive and has the fewest side effects for most women.
The Pill uses one estrogenic compound and one progestagenic compound to raise blood levels. When the hypothalamus in the brain senses the presence of these hormones, it does not signal the ovary to begin the egg-development process. This normally occurs through the release of FSH and LH.
The end result is a quiet ovary that does not ovulate or produce the normal ovarian hormone contribution. Thus, we trade the ovary’s normal hormones for the low-dose, well-regulated combination of hormones that come from the pill. Although this explanation is a little simplified, I think it does explain the basic process.
What Others Do
Some physicians prescribe post-op ovarian suppression routinely. Although it is inappropriate for me to imply that I know the reasoning of every surgeon, I will list the reasons that I hear most often at meetings, on medical records, and from the patients of those physicians.
- Prevents more endometriosis from returning as quickly as it otherwise would.
- Allows more complete healing of the injured tissues before allowing the next ovarian cycle.
- Minimizes stimulation of the endometriosis they left behind.
- Is good practice to keep patients on some form of suppression unless they are actively trying to conceive.
What I Used to Think
I have discussed post-operative ovarian suppression before in this newsletter. It had been my belief that if all a woman's endometriosis has been completely excised, there was no real reason to recommend suppression as a form on ongoing treatment after surgery.
Therefore, I have consistently used simple ovarian suppression with oral contraceptives only when contraception was the objective. I do not use the stronger drugs (Lupron, Synarel, Danazol, RU-486, Zoladex) for this purpose at all.
Avoiding the unnecessary use of medications saves money, prevents side effects, and gives the patient a better opportunity to evaluate the improvement in her pain after surgery at the Center for Endometriosis Care.
What I Think NOW
It had been my policy to not suppress a patient post-op, except for contraceptive reasons. However, I have begun to prescribe a short-term interval of post-op ovarian suppression for a period of two to three months, in specific situations and for a specific benefit.
As we have followed our patients through the first three months after their surgery, we have observed that women who had certain procedures experienced much more pain during their first months of recovery. These procedures are the excision of an ovarian cyst or a cystectomy.
Some of these individuals do well at first, but then start their menstrual period before the expected time. This may greatly increase the pain they are experiencing. When I reviewed the charts for these patients, I found that many of them had a cyst removed from an area of the ovary where the developing follicle or corpus luteum was, and so it was removed as well. This stops the production of estrogen and progesterone, and so menses began.
Another group of women seems to be recovering nicely, then have a sudden increase in their pain around the time of expected ovulation in the first or second cycle after surgery. This may be due to an interruption in the capsule of an ovary recently operated on. The ovary is still swollen and injured from the recent cystectomy. It is extremely tender. Some of these ovaries generate a very small amount of internal bleeding, which is almost always temporary but extremely painful.
Because of these experiences, I now consider the amount and nature of ovarian surgery I have performed before I make a recommendation regarding ovarian suppression.
I believe that if cystectomy is required in order to completely excise a woman’s endometriosis, the use of oral contraceptives for the first three months post-op may help avoid unnecessary pain as related to the events described above.
At the end of the first three months, I see no reason to continue the suppression unless the objective is to avoid pregnancy.