Overview of Reviews

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Endometriosis: an overview of Cochrane Reviews

  1. Julie Brown1,*,
  2. Cindy Farquhar2

Editorial Group: Cochrane Menstrual Disorders and Subfertility Group

Published Online: 10 MAR 2014

Assessed as up-to-date: 6 MAR 2014

DOI: 10.1002/14651858.CD009590.pub2


How to Cite

Brown J, Farquhar C. Endometriosis: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD009590. DOI: 10.1002/14651858.CD009590.pub2.

Author Information

  1. 1

    The University of Auckland, Liggins Institute, Auckland, New Zealand

  2. 2

    University of Auckland, Department of Obstetrics and Gynaecology, Auckland, New Zealand

*Julie Brown, Liggins Institute, The University of Auckland, Park Rd, Grafton, Auckland, 1142, New Zealand. j.brown@auckland.ac.nz.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 10 MAR 2014

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 淺顯易懂的口語結論

Background

This overview reports on interventions for pain relief and for subfertility in pre-menopausal women with clinically diagnosed endometriosis.

Objectives

The objective of this overview was to summarise the evidence from Cochrane systematic reviews on treatment options for women with pain or subfertility associated with endometriosis.

Methods

Published Cochrane systematic reviews reporting pain or fertility outcomes in women with clinically diagnosed endometriosis were eligible for inclusion in the overview. We also identified Cochrane reviews in preparation (protocols and titles) for future inclusion. The reviews, protocols and titles were identified by searching the Cochrane Database of Systematic Reviews and Archie (the Cochrane information management system) in March 2014.

Pain-related outcomes of the overview were pain relief, clinical improvement or resolution and pain recurrence. Fertility-related outcomes were live birth, clinical pregnancy, ongoing pregnancy, miscarriage and adverse events.

Selection of systematic reviews, data extraction and quality assessment were undertaken in duplicate. Review quality was assessed using the AMSTAR tool. The quality of the evidence for each outcome was assessed using GRADE methods. Review findings were summarised in the text and the data for each outcome were reported in 'Additional tables'.

Main results

Seventeen systematic reviews published in The Cochrane Library were included. All the reviews were high quality. The quality of the evidence for specific comparisons ranged from very low to moderate. Limitations in the evidence included risk of bias in the primary studies, inconsistency between the studies, and imprecision in effect estimates.

Pain relief (14 reviews)

Gonadotrophin-releasing hormone (GnRH) analogues

One systematic review reported low quality evidence of an overall benefit for GnRH analogues compared with placebo or no treatment.

Ovulation suppression

Five systematic reviews reported on medical treatment using ovulation suppression. There was moderate quality evidence that the levonorgestrel-releasing intrauterine system (LNG-IUD) was more effective than expectant management, and very low quality evidence that danazol was more effective than placebo. There was no consistent evidence of a difference in effectiveness between oral contraceptives and goserelin, estrogen plus progestogen and placebo, or progestogens and placebo, though in all cases the relevant evidence was of low or very low quality.

Non-steroidal anti-inflammatory drugs (NSAIDS)

A review of NSAIDs reported inconclusive evidence of a benefit in symptom relief compared with placebo.

Surgical interventions

There were two reviews of surgical interventions. One reported moderate quality evidence of a benefit in pain relief following laparoscopic surgery compared to diagnostic laparoscopy only. The other reported very low quality evidence that recurrence rates of endometriomata were lower after excisional surgery than after ablative surgery.

Post-surgical medical interventions

Two reviews reported on post-surgical medical interventions. Neither found evidence of an effect on pain outcomes, though in both cases the evidence was of low or very low quality.

Alternative medicine

There were two systematic reviews of alternative medicine. One reported evidence of a benefit from auricular acupuncture compared to Chinese herbal medicine, and the other reported no evidence of a difference between Chinese herbal medicine and danazol. In both cases the evidence was of low or very low quality.

Anti-TNF-α drugs

One review found no evidence of a difference in effectiveness between anti-TNF-α drugs and placebo. However, the evidence was of low quality.

Reviews reporting fertility outcomes (8 reviews)

Medical interventions

Four reviews reported on medical interventions for improving fertility in women with endometriosis. One compared three months of GnRH agonists with a control in women undergoing assisted reproduction and found very low quality evidence of an increase in clinical pregnancies in the treatment group. There was no evidence of a difference in effectiveness between the interventions in the other three reviews, which compared GnRH agonists versus antagonists, ovulation suppression versus placebo or no treatment, and pre-surgical medical therapy versus surgery alone. In all cases the evidence was of low or very low quality.

Surgical interventions

Three reviews reported on surgical interventions. There was moderate quality evidence that both live births or ongoing pregnancy rates and clinical pregnancy rates were higher after laparoscopic surgery than after diagnostic laparoscopy alone. There was low quality evidence of no difference in effectiveness between surgery and expectant management for endometrioma. One review found low quality evidence that excisional surgery resulted in higher clinical pregnancy rates than drainage or ablation of endometriomata.

Post-surgical interventions

Two reviews reported on post-surgical medical interventions. They found no evidence of an effect on clinical pregnancy rates. The evidence was of low or very low quality.

Alternative medicine

A review of Chinese herbal medicine in comparison with gestrinone found no evidence of a difference between the groups in clinical pregnancy rates. However, the evidence was of low quality.

Adverse events

Reviews of GnRH analogues and of danazol reported that the interventions were associated with higher rates of adverse effects than placebo; and depot progestagens were associated with higher rates of adverse events than other treatments. Chinese herbal medicine was associated with fewer side effects than gestrinone or danazol.

Three reviews reported miscarriage as an outcome. No difference was found between surgical and diagnostic laparoscopy, between GnRH agonists and antagonists, or between aspiration of endometrioma and expectant management. However, in all cases the quality of the evidence was of low quality.

Authors' conclusions

For women with pain and endometriosis, suppression of menstrual cycles with gonadotrophin-releasing hormone (GnRH) analogues, the levonorgestrel-releasing intrauterine system (LNG-IUD) and danazol were beneficial interventions. Laparoscopic treatment of endometriosis and excision of endometriomata were also associated with improvements in pain. The evidence on NSAIDs was inconclusive. There was no evidence of benefit with post-surgical medical treatment.

In women with endometriosis undergoing assisted reproduction, three months of treatment with GnRH agonist improved pregnancy rates. Excisional surgery improved spontaneous pregnancy rates in the nine to 12 months after surgery compared to ablative surgery. Laparoscopic surgery improved live birth and pregnancy rates compared to diagnostic laparoscopy alone. There was no evidence that medical treatment improved clinical pregnancy rates.

Evidence on harms was scanty, but GnRH analogues, danazol and depot progestagens were associated with higher rates than other interventions.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 淺顯易懂的口語結論

Endometriosis: an overview of Cochrane Reviews

Background

Cochrane review authors examined the evidence on endometriosis from Cochrane systematic reviews published in The Cochrane Library. We aimed to summarise the evidence on treatment options that are available to women with pain or subfertility, or both, associated with clinically diagnosed endometriosis.

Study characteristics

We included 17 Cochrane systematic reviews. Fourteen reported measures of pain relief and eight reported fertility outcomes. All the reviews were high quality. The quality of the evidence for specific comparisons and outcomes ranged from very low to moderate, due to limitations in the primary studies, inconsistency between the studies and imprecision in the findings.

Key results

A number of interventions appeared effective in alleviating pain in women with endometriosis. These were gonadotrophin-releasing hormone (GnRH) analogues when compared with placebo, the levonorgestrel-releasing intrauterine system (LNG-IUD) compared with expectant management, danazol compared with placebo, and progestagens and anti-progestagens compared with placebo. Laparoscopic surgical interventions also appeared to be effective for pain.

In women with endometriosis undergoing assisted reproduction, three months of treatment with GnRH agonist improved pregnancy rates. Excisional surgery improved spontaneous pregnancy rates in the nine to 12 months after surgery compared to ablative surgery. Laparoscopic surgery improved live birth and pregnancy rates compared to diagnostic laparoscopy alone. There was no evidence that medical treatment improved clinical pregnancy rates.

Evidence on harms was scanty but GnRH analogues and danazol were associated with higher rates of adverse effects than placebo, and depot progestagens were associated with higher rates than other treatments.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 淺顯易懂的口語結論

子宮內膜異位症:縱觀考科藍文獻回顧

背景

本次文獻回顧針對臨床診斷為子宮內膜異位症 (endometriosis) 的停經前女性,探究緩解疼痛及治療低生育力 (subfertility) 的相關介入。

目的

本次文獻回顧的目的旨在概述來自考科藍系統性文獻回顧的證據,探討子宮內膜異位症女性患者的疼痛或低生育力治療選擇。

方法

本次文獻回顧納入已發表的考科藍系統性文獻回顧,探討臨床診斷為子宮內膜異位症的女性患者,其疼痛或生育力結果。我們也找尋籌備中的考科藍文獻回顧 (試驗計畫書與標題),以備未來將其納入文獻回顧。我們於2014年3月搜尋考科藍系統性回顧暨檔案檢索系統 (Cochrane Database of Systematic Reviews and Archie) (考科藍資訊管理系統),找尋文獻回顧、試驗計畫書和標題。

文獻回顧的疼痛相關結果為疼痛緩解、臨床改善或治癒,以及疼痛復發。生育力相關結果則為活產、臨床懷孕 (clinical pregnancy)、持續懷孕 (ongoing pregnancy)、流產和不良事件。

以一式兩份的方式選擇系統性文獻回顧、萃取資料和評估品質。利用AMSTAR工具評估文獻回顧的品質,並採用GRADE方法評估各項結果的證據品質。回顧結果匯整摘述於內文,並以「附表」的方式呈現各項結果的數據。

主要結果

我們納入17篇發表於考科藍圖書館的系統性文獻回顧,所有文獻回顧均具有高品質。具體比較的證據品質範圍介於極低至中等之間,證據的限制包括原始試驗的偏差風險、各試驗之間的不一致性,以及效果估計不夠精確。

緩解疼痛 (14篇文獻回顧)

促性腺激素釋放素 (Gonadotrophin-releasing hormone, GnRH) 類似物

有1篇系統性文獻回顧指出,相對於安慰劑或無治療組,GnRH 的整體效益證據品質偏低。

抑制排卵

有5篇系統性文獻回顧探討抑制排卵作用的內科治療。「levonorgestrel 子宮內投藥系統 (levonorgestrel-releasing intrauterine system, LNG-IUD) 療效優於預期處置 (expectant management)」的證據品質中等;「danazol優於安慰劑」的證據品質極低。關於口服避孕藥和goserelin、雌激素 (estrogen) 加黃體素 (progestonge) 和安慰劑,或黃體素和安慰劑的療效差異比較,所得到的證據並不一致,雖然所有相關證據的品質均偏低或極低。

非類固醇類消炎劑 (Non-steroidal anti-inflammatory drug, NSAID)

關於NSAID的文獻回顧指出,相對於安慰劑,並無明確證據顯示NSAID可有效緩解症狀。

外科手術介入

有2篇關於外科手術介入的文獻回顧,其中1篇文獻回顧指出,相較於僅進行診斷性腹腔鏡檢查 (laparoscopy),「腹腔鏡外科手術後可緩解疼痛」的證據品質中等;另1篇文獻回顧指出相較於分離手術 (ablative surgery),切除手術 (excisional surgery) 後子宮內膜異位瘤 (endometriomata) 的復發率較低,但證據品質極低。

手術後內科介入

有2篇文獻回顧提出關於手術後內科介入的報告,並未發現對疼痛結果具有影響,雖然2篇文獻回顧所收集的證據品質偏低或極低。

另類醫學

有2篇關於另類醫學的系統性文獻回顧,其中1篇提出耳針 (auricular acupuncture) 的療效優於中草藥 (Chinese herbal medicine) 的證據,另1篇則指出並無證據顯示中草藥和danazol的療效具有差異。2篇文獻回顧所收集的證據品質偏低或極低。

抗α腫瘤壞死因子藥物 (Anti-TNF-α drug)

有1篇文獻回顧發現,並無證據顯示抗α腫瘤壞死因子藥物的療效,與安慰劑不同。不過此篇文獻回顧所收集的證據品質偏低。

生育力結果的文獻回顧 (8篇文獻回顧)

內科介入

有4篇文獻回顧提出以內科介入,改善子宮內膜異位症患者生育力的相關報告。有1篇文獻回顧針對接受人工協助生殖 (assisted reproduction) 的女性,比較3個月的GnRH促效劑組和對照組,結果發現治療組的臨床懷孕率增加,但證據品質極低。其他3篇文獻回顧,並未發現這些介入具有療效差異,上述文獻回顧比較GnRH促效劑和拮抗劑、排卵抑制和安慰劑或無治療介入,以及手術前內科治療與單獨使用外科手術等介入方式。所有文獻回顧收集的證據品質均偏低或極低。

外科手術介入

有3篇文獻回顧提出關於外科介入的報告。相較於單獨使用診斷性腹腔鏡檢查,進行腹腔鏡手術後患者的活產或持續懷孕率與臨床懷孕率均較高,此項證據品質中等。外科手術和預期處置對子宮內膜異位瘤的療效並無差異,此項證據品質偏低。有1篇文獻回顧發現,相較於子宮內膜異位瘤引流或分離手術,切除手術後的臨床懷孕率較高,此項證據品質低。

手術後介入

有2篇文獻回顧報告外科手術後的內科介入。研究者並未發現對臨床懷孕率有影響的證據,此項證據品質偏低或極低。

另類醫學

有1篇文獻回顧比較中草藥與gestrinone,並未發現2個治療組的臨床懷孕率有差異,不過此項證據品質偏低。

不良作用

GnRH類似物和danazol的文獻回顧指出,這些介入的不良作用發生率高於安慰劑;持續型黃體素 (depot progestagen) 的不良事件發生率高於其他治療。中草藥的副作用比gestrinone或danazol少。

有3篇文獻回顧以流產為結果。外科手術和診斷性腹腔鏡檢查、GnRH促效劑和拮抗劑,或子宮內膜瘤抽吸術和預期處置的流產發生率,並無組間差異。不過所有的證據品質皆偏低。

作者結論

對於有經痛和子宮內膜異位症的女性患者,使用促性腺激素釋放素 (Gonadotrophin-releasing hormone, GnRH) 類似物、levonorgestrel 子宮內投藥系統 (levonorgestrel-releasing intrauterine system, LNG-IUD)和danazol抑制月經週期,可能是有效的治療方法。以腹腔鏡手術治療子宮內膜異位症並切除子宮內膜瘤,也可以改善疼痛症狀。NSAID的證據比較不明確,並無證據顯示手術後的內科治療具有療效。

對於進行人工協助生殖的子宮內膜異位症女性患者,接受3個月的GnRH促效劑治療可以提高懷孕率。相對於分離手術,切除手術將可提高手術後9至12個月內的自然懷孕率。相較於僅使用診斷性內視鏡檢查,內視鏡手術可提高活產和懷孕率。並無證據顯示內科治療能提高臨床懷孕率。

雖然極為欠缺傷害的相關證據,但GnRH類似物、danazol和持續型黃體素的不良作用發生率,高於其他介入。

 

淺顯易懂的口語結論

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 淺顯易懂的口語結論

子宮內膜異位症:縱觀考科藍文獻回顧

背景

考科藍文獻回顧作者依據考科藍圖書館所發表的考科藍系統性文獻回顧,檢視子宮內膜異位症的證據。我們的目的在於摘述經臨床診斷患有子宮內膜異位症,並因此出現經痛或低生育力或兩者的女性可利用的治療選擇。

試驗特色

我們納入17篇考科藍系統性文獻回顧,其中有14篇文獻回顧提及疼痛緩解的狀況,有8篇文獻回顧報告生育力的結果。所有的文獻回顧品質皆高,但受限於原始試驗、各試驗間的不一致性,以及結果不夠精確,具體比較和結果的證據品質,則介於極低至中等之間。

重要結果

某些介入顯然可有效緩和子宮內膜異位症女性患者的疼痛症狀,包括促性腺激素釋放素 (Gonadotrophin-releasing hormone, GnRH) 類似物 (相對於安慰劑)、levonorgestrel 子宮內投藥系統 (levonorgestrel-releasing intrauterine system, LNG-IUD) (相對於預期處置 [expectant management])、danazol (相對於安慰劑),以及黃體素和抗黃體素 (相對於安慰劑)。內視鏡手術介入顯然也可有效緩解經痛。

對於進行人工協助生殖的子宮內膜異位症女性患者,接受3個月的GnRH促效劑治療可以提高懷孕率。相對於分離手術,切除手術將可提高手術後9至12個月內的自然懷孕率。相較於僅使用診斷性內視鏡檢查,內視鏡手術可提高活產和懷孕率。並無證據顯示內科治療能提高臨床懷孕率。

雖然非常欠缺關於傷害的證據,但GnRH類似物和danazol的不良作用發生率高於安慰劑;而持續型黃體素的不良作用發生率,則高於其他介入。

譯註


翻譯者:臺北醫學大學實證醫學研究中心
本翻譯計畫由衛生福利部補助經費,臺北醫學大學實證醫學研究中心、台灣實證醫學學會及東亞考科藍聯盟(EACA)統籌執行。