What adjustments should be made to the medication regimen of a patient with Stage III endometriosis and a history of pelvic surgery, who is taking combined hormonal contraceptives, to minimize complications and manage symptoms prior to an upcoming surgery?

Preoperative Medication Management for Stage III Endometriosis

Continue combined hormonal contraceptives without interruption until 2-4 weeks before surgery, then discontinue to reduce venous thromboembolism risk while maintaining symptom control through the preoperative period. 1

Immediate Preoperative Adjustments (2-4 Weeks Before Surgery)

• Discontinue combined hormonal contraceptives 2-4 weeks preoperatively to minimize VTE risk, as the CDC classifies surgery with prolonged immobilization as a Category 4 condition (unacceptable health risk) for combined hormonal contraceptive use 1

• If pain symptoms worsen after discontinuation, consider bridging with NSAIDs for pain control during the final 1-2 weeks before surgery, as these do not increase surgical bleeding risk when stopped 24-48 hours preoperatively 2, 3

• Do not initiate GnRH agonist therapy at this late stage, as these agents require 4-6 weeks to achieve maximal suppression and cause initial estrogen flare that could worsen symptoms 4, 5

Contraceptive Management Timeline

• If <48 hours since last missed pill: Take the missed pill immediately and continue the pack as scheduled with no backup contraception needed 1

• If ≥48 hours or multiple missed pills: Take the most recent missed pill, continue remaining pills, use backup contraception for 7 consecutive days, and consider emergency contraception if unprotected intercourse occurred in the previous 5 days 1

• For the final 2-4 weeks preoperatively: Use barrier contraception methods only after discontinuing hormonal contraceptives 1

Postoperative Medication Planning

• Resume combined hormonal contraceptives >42 days postoperatively if no other VTE risk factors are present, or wait until full mobilization is achieved if additional risk factors exist 1

• Consider switching to progestin-only options postoperatively (levonorgestrel IUD, dienogest, or norethindrone acetate) as these carry lower VTE risk and are equally effective for endometriosis pain control 3, 6, 7

• The levonorgestrel-releasing IUS is particularly effective for preventing endometrioma recurrence and can be placed at the time of surgery 6, 7

Critical Perioperative Considerations

• Avoid progestational agents as adjuvant therapy, as Level I evidence demonstrates they do not increase survival or improve outcomes in endometrial disease management 1, 8

• Ensure adequate VTE prophylaxis with mechanical compression devices and early mobilization, given the dual risk from both surgery and recent hormonal contraceptive use 1

• Screen for anemia preoperatively given the history of Stage III endometriosis with likely chronic blood loss; optimize iron stores if hemoglobin <12 g/dL 2

Common Pitfalls to Avoid

• Do not continue combined hormonal contraceptives through surgery, as this substantially increases VTE risk during the perioperative period when immobilization compounds thrombotic risk 1

• Do not abruptly stop hormonal contraceptives months before surgery, as this allows disease progression and symptom recurrence; the 2-4 week window balances VTE risk reduction with symptom control 3, 6

• Do not start new hormonal therapies in the immediate preoperative period, as side effects and adjustment periods may complicate surgical planning and recovery 5, 7