Study design. Randomized, comparative and controlled clinical trial (CT) whose protocol (ENDOMET-IA-DIULNG08) was approved by the Ethics Committee of San Juan University Hospital (26-August-2008). It was registered in the Eudra CT System of the European Medicines Agency (London, 29-Sept-2008; Nº EudraCT: 2008-005744-17) (07/11/2008) and then authorized by the Spanish Agency for Medicines and Health Products (AEMPS) (10/11/2008).
Participants: Premenopausal women with endometriomas recruited at the Endometriosis and Reproductive Medicine Consultation of San Juan University Hospital. They had been advised for CS, did not currently desire pregnancy, and accepted the insertion of LNG-IUD (Mirena®) for 6 months and randomization to perform conservative surgery (CS) with ovarian and fertility-sparing by laparoscopy or laparotomy, or only transvaginal ultrasound-guided puncture-aspiration (TUGPA) of endometriomas, 1 month after the IUD insertion.
Inclusion criteria: Young women (< 41 y) with significant clinical symptoms (score of visual analogue scale (VAS) ≥ 4), elevated CA-125 (≥ 35 U/mL), and a transvaginal ultrasound (TVU) with suggestive findings of endometriomas (> 3×4 cm). These patients could have a previous diagnosis and treatment (medical and/or surgical) of endometriosis, but they should not have received medical treatment in the last 3 months.
Exclusion criteria: i) Pregnancy; ii) Infertility with current desire for pregnancy; iii) No previous sexual intercourse and/or non-acceptance of insertion of Mirena®; iv) Acute or recurrent pelvic inflammatory disease or genital tract infection; v) Uterine malformations and/or leiomyomas; vi) Any medical pathology that could contraindicate the treatment with Anastrozole or LNG-IUD (Mirena®).
Written informed consent was obtained from all patients before randomization. Participants were randomized by computer, determined at the Hospital Pharmacy after a telephone call from the Endometriosis Consultation. Between January 15, 2009 (date of inclusion of the first patient) and March 15, 2015, the eligibility criteria were analyzed in 52 patients who had ovarian cystic tumors suggestive of endometriomas, with indication to CS. After excluding 21 patients due to not meeting all the inclusion criteria, doubts in the ultrasound diagnosis, or because they declined to participate, the other 31 women were included, randomized, treated and followed up according to the following subgroups: (1) Anastrozole-Mirena-CS (n = 8); (2) Anastrozole-Mirena-TUGPA (n = 7); (3) no Anastrozole-Mirena-CS (n = 9); and (4) no Anastrozole-Mirena-TUGPA (n = 7).
Procedures. Medical treatments: (1) oral Anastrozole, 1 tablet of 1 mg daily for 6 months administered to patients in subgroups 1 and 2; (2) LNG-IUD (Mirena®) for all patients; (3) calcium carbonate and cholecalciferol (Ca + Vitamin D) to patients taking Anastrozole to avoid the damaging effects of AI on the bone. Surgical treatments: (1) laparoscopy (in 13 women, 76%) or laparotomy (in 4 women -in 2 was conversion-) with CS of endometriosis; or (2) TUGPA of endometriomas (in 14 women). All surgeries were performed or directed by the first author of the present study (PA).
Research plan: All patients will undergo a first analytical control, clinical exploration and TVU in the second half of the cycle, being randomized according to the subgroups previously exposed. Patients of subgroups 1 and 2 would start taking Anastrozole at the beginning of the next menstruation, placing the LNG-IUD (Mirena®) during it, as well as in the other subgroups. At the time, the surgical proposal to be practiced a month later was processed. Postoperative control follow-ups would be done at 3 and 6 months (time of withdrawal of Anastrozole and Mirena®); thereafter at 9, 12, 18, 24 months, and then annual follow-ups.
Assessments. All patients must have a detailed medical history about their antecedents and previous treatments, also including clinical exploration, TVU, hormonal and tumor marker analysis (CA-125, CA-19-9) and symptoms score using our VAS [maximum 10 points, including dysmenorrhea (0-3), deep dyspareunia (0-3), chronic pelvic pain (CPP, 0-3), and others (0-1)]. In all subsequent follow-ups, TVU, analysis and VAS score for symptoms were repeated.
We considered recurrence of the disease when an endometrioma was detected in any control, which persisted or grew in subsequent follow-ups, associated with an increase in VAS score and/or CA-125 level. In any case, the recurrences of small endometriomas (1.5-3 cm) and endometriomas greater than 3×4 cm are presented separately in the tables of results.
Outcomes. Primary endpoint: clinical, analytical and ultrasound improvement assessed by (1) reduction or disappearance of symptoms; (2) normalization of CA-125 values; (3) reduction or disappearance of endometriomas. These parameters were studied in each postoperative control follow-up at 3 and 6 months; thereafter at 9, 12, 18, 24 months, and then in annual follow-ups. Secondary endpoints: (1) decrease or disappearance of recurrences; (2) rate of reoperations; (3) subsequent pregnancy achievement; and (4) valuation of the clinical state in the last follow-up and the need for other treatments.
Safety and adverse events. In laparoscopic or laparotomic surgery, peritoneal fluid and biopsies or surgical specimens were collected for cytological and histopathological studies. In TUGPA, endometrioma fluids were also collected for cytological analysis. Side effects and adverse events were registered and considered in each patient follow-up.
Statistical analysis. Sample size: Based on previously published studies using AI [3,4,12,13] or LNG-IUD , we estimated a total sample size of 48 patients (12 in each subgroup) to study in a period of 3 years, which was prolonged another 3 years due to difficulties for recruitment. However, we decided to finish it in March 2015 due to its low rate, to the need to make a final report in September-2015 and also because the patients undergoing TUGPA were not showing good clinical results. Nevertheless, their follow-up continued to the final data collection in July-2017.
All data were entered into SPSS Statistics version 25.0 (IBM, Spain) to perform statistical analysis. Data are expressed as percentages, mean ± standard deviation (SD), median, minimum and maximum (min-max) values, and a 95% confidence interval (CI) (if applicable). The main dependent variables were the VAS score, the absence or presence of endometriomas in TVU, and the values of CA-125, as well as their evolution in later follow-ups. The main independent variables were Anastrozole+LNG-IUD or only LNG-IUD treatments, as well as CS or TUGPA of endometriomas. We applied descriptive statistical analysis for qualitative variables to determine frequencies and distribution using contingency tables and comparison of proportions. The chi-squared, Kruskal-Wallis, Mann-Whitney U and correlation tests were used to compare groups and parameters in the different follow-ups. For quantitative or numerical variables, we applied nonparametric tests for paired data to compare the values before and at 3, 6, and 9 months, and 1 and 2 years, and the last follow-up after treatment, calculating the Wilcoxon signed rank test, the signs test, the McNemar test (for dichotomous variants), and the marginal homogeneity test, noting in tables and graphs only the significant results. Likewise, nonparametric tests were applied to compare Anastrozole and non-Anastrozole groups. To determine the recurrence and reoperation rates, we calculated the percentage accumulated every 3 months up to 2 years, and then every year up to 6 years, pointing at the corresponding figures the patients at risk in each period, subtracting recurrences and loss to follow-up. All p values reported are 2-tailed, and p<0.05 was considered significant.