Can scar endometriosis in a reproductive‑age woman with a painful cyclic nodule at a prior cesarean scar be treated with oral hormonal therapy?

Management of Scar Endometriosis

Surgical excision is the definitive treatment for cesarean scar endometriosis, as medical hormonal therapy alone is insufficient for this condition. 1, 2, 3

Why Surgery is the Standard of Care

Scar endometriosis differs fundamentally from pelvic endometriosis in its response to treatment. While pelvic endometriosis responds well to hormonal suppression, scar endometriosis involves endometrial tissue embedded within the abdominal wall tissues (subcutaneous tissue and rectus sheath), making it largely inaccessible to systemic hormonal manipulation. 3, 4

• Wide local excision is the method of choice for scar endometriosis, with complete resolution of symptoms and no recurrence reported in surgical case series. 3
• The lesion typically involves subcutaneous tissue in all cases, with rectus sheath involvement in approximately 69% of patients. 3
• Mean lesion size is approximately 2.8 cm, requiring adequate surgical margins for complete excision. 3

Limited Role of Oral Hormonal Therapy

While oral hormonal medications (combined oral contraceptives, progestins, GnRH agonists, danazol) are first-line treatments for pelvic endometriosis 5, 6, 7, these agents have no established efficacy for scar endometriosis. The literature on scar endometriosis consistently describes surgical management as the primary treatment, with no studies demonstrating successful resolution with medical therapy alone. 1, 2, 3, 8, 4

• Danazol is FDA-approved for endometriosis amenable to hormonal management 9, but scar endometriosis does not fall into this category.
• The role of postoperative medical management to reduce recurrence after surgical excision requires further prospective studies and is not currently standard practice. 3

Clinical Presentation to Confirm

Before proceeding to surgery, ensure the diagnosis is consistent with scar endometriosis:

• Cyclical pain and swelling at the cesarean scar site is present in 93.8% of cases. 3
• Mean interval from cesarean section to presentation is approximately 4.5 years. 3
• Ultrasound imaging typically reveals a nodular lesion with characteristic features. 1, 2
• Fine needle aspiration cytology can confirm the diagnosis preoperatively and rule out malignancy. 1

Important Caveats

• Concurrent pelvic endometriosis is present in approximately 19% of women with scar endometriosis. 3 If pelvic symptoms coexist, these may benefit from hormonal therapy as adjunctive treatment for the pelvic component.
• The diagnosis can mimic carcinoma, requiring histopathological confirmation. 1
• Scar endometriosis is increasing in prevalence due to rising cesarean section rates, with an estimated incidence of 0.03-0.4% after cesarean delivery. 8