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Menopause endometriosis: Endometriosis in Menopause—Renewed Attention on a Controversial Disease

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Endometriosis in Menopause—Renewed Attention on a Controversial Disease

Diagnostics (Basel). 2020 Mar; 10(3): 134.

Paul Pirtea

2Department of Ob Gyn and Reproductive Medicine, Hopital Foch—Faculté de Medicine Paris Ouest (UVSQ), 92151 Suresnes, France; [email protected]

2Department of Ob Gyn and Reproductive Medicine, Hopital Foch—Faculté de Medicine Paris Ouest (UVSQ), 92151 Suresnes, France; [email protected]

Received 2020 Jan 13; Accepted 2020 Feb 27.

Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).This article has been cited by other articles in PMC.

Abstract

Endometriosis, an estrogen-dependent inflammatory disease characterized by the ectopic presence of endometrial tissue, has been the topic of renewed research and debate in recent years. The paradigm shift from the belief that endometriosis only affects women of reproductive age has drawn attention to endometriosis in both premenarchal and postmenopausal patients. There is still scarce information in literature regarding postmenopausal endometriosis, the mostly studied and reported being the prevalence in postmenopausal women. Yet, other important issues also need to be addressed concerning diagnosis, pathophysiology, and management. We aimed at summarizing the currently available data in literature in order to provide a concise and precise update regarding information available on postmenopausal endometriosis.

Keywords: endometriosis, menopause, diagnosis, management, malignancy

1. Introduction

The concept that endometriosis is a disease that only affects women of reproductive age has prevailed since 1942, when the first case of endometriosis in a postmenopausal patient was reported by Edgar Haydon [1].

In spite of this early report, endometriosis has also been described in premenarchal patients and is a common occurrence in adolescents [2,3,4].

The recurrence of endometriosis lesions in patients with a prior diagnosis of endometriosis during the premenopausal period or the de novo appearance of endometriosis in postmenopausal patients with no prior history of endometriosis-related complaints has been however well documented in numerous case series, case reports, and retrospective studies [5,6,7,8,9].

The management of endometriosis in postmenopause and hormone replacement therapy (HRT) in patients with a history of endometriosis remains controversial.

2. Prevalence

The incidence of postmenopausal endometriosis reported in literature is of approximately 2–5%. It commonly represents a side effect of HRT, rarely occurring in patients without a history of HRT or Tamoxifen treatment [10]. In a few cases, postmenopausal endometriosis has been described in women who had no history of endometriosis on imaging or surgery prior to menopause [11].

In order to evaluate the prevalence of postmenopausal endometriosis, Haas et al. performed a retrospective epidemiological study on 42,079 women admitted for surgical treatment with histologically confirmed endometriosis. Patients were sorted in 5 years age groups and also in premenopausal, perimenopausal, and postmenopausal subgroups. The results showed that 33,814 patients (80.36%) were in the premenopausal group (age 0–45 years), with 23 patients (0. 05%) being younger than 15 years; of the remaining patients, 7191 (17.09%) were in the perimenopausal (45–55 years), and 1074 patients (2.55%) in the postmenopausal group, respectively [6].

3. Pathophysiology

Endometriosis is an estrogen-dependent inflammatory disease characterized by the presence of ectopic endometrial tissue. The pathogenesis of endometriosis remains enigmatic [12].

Postmenopausal endometriosis is considered to have an even more complex pathophysiology than premenopausal endometriosis. It is still unclear whether this represents a recurrence or continuation of a previous disease or a de novo condition. Excess estrogen, in general, represents a promoting factor for endometriosis. The arrest of estrogen production at the level of the ovaries at the time of menopause is counterbalanced by peripheral estrogen production from conversion of androgens (especially in the adipose tissue and skin). The leading estrogen found in these patients is estrone.

An attractive theory regarding the pathogenic mechanism of postmenopausal endometriosis involves the “estrogen threshold”, i. e., when a certain estrogen level is reached or surpassed in postmenopausal patients it activates undetected or “transient” foci of endometriosis.

In addition to the peripheral estrogen production, a high circulating level of estrogen may be of external source, especially in the form of phytoestrogens and HRT. Phytoestrogens appear to exert estrogenic effects on the uterus, breast, and pituitary and could also support the growth of endometriotic lesions [13,14,15].

Despite the fact that postmenopausal endometriosis has the same immunochemical profile as premenopausal endometriosis and has the potential to reactivate under estrogen stimulation, endometriosis lesions in the postmenopausal period seem to be less common, less extensive, and less active in most cases [16].

4. Symptomatology

The clinical presentation of endometriosis in menopausal patients is unspecific, such as pelvic pain, ovarian cysts, or intestinal symptoms. Given the age of the patients, they are often suspected of a neoplastic process. As a general consideration, all postmenopausal patients should be evaluated for malignancy if a new suspicious structure is found on ultrasound examination.

In menopausal women with a history of endometriosis, the drop in estrogen levels after menopause relieves the endometriosis-related symptoms but generates specific menopausal ones, such as mood swings, hot flushes, vaginal atrophy, and night sweats [5,17]. The clinical grim reality is that the severity of the disease is not necessarily reflected in the degree of discomfort. Commonly, the complaints of pelvic pain underestimate the disease’s severity in both premenopausal and postmenopausal endometriosis.

5. Diagnosis

Despite intensive research conducted in the last decades, endometriosis remains a disease with a delayed diagnosis, especially in older patients. This results from the lack of noninvasive tools available for early stage diagnosis. For many years, there has been a long-standing myth that endometriosis is a disease that affects only adult women of reproductive age. However, in recent years, focus has turned to the diagnosis of endometriosis in postmenopausal patients, given that the onset of pain can start after the onset of menopause, with reports of endometriosis occurring even in 80-year-old patients [1,5].

The ovaries are the most common location of endometriotic lesions in postmenopausal patients (79.2% of cases) [18].

Distinction between endometriosis lesions and cancer is complicated by the fact that some of the risk factors are similar, such as low parity rate, infertility, late childbearing age, and a short duration of oral contraceptive use [19].

Currently, laparoscopy and biopsy for histological confirmation of suspicious lesions is the gold standard for diagnosis of endometriosis, irrespective of age. Laparoscopy, the standard technique for inspecting the pelvis, can provide simultaneous diagnosis and treatment of lesions. Additional tools are needed for a noninvasive diagnostic and classification. To this date, no serum marker or test is available for reliably diagnosing endometriosis [20,21]. Regarding imaging investigations, MRI and ultrasound are important, but findings are more difficult to interpret in menopausal patients than in younger patients due to the higher suspicion for neoplastic lesions and the polymorphic aspect of endometriosis.

5.1. Clinical Examination

The patient’s medical history, clinical examination, or preoperative symptoms have a limited role in determining the extent of endometriosis lesions as there is no direct relationship between symptoms and the anatomic-surgical characteristics of endometriotic lesions [22]. Also, there is usually a discrepancy between the severity of symptoms and the extent of lesions with many patients whose severe lesions remain asymptomatic. This is an important factor contributing to a delay of approximately 6 to 8 years from onset of symptoms to diagnosis in premenopausal and postmenopausal patients alike [23].

Pelvic vaginal and rectal examination is useful in identifying endometriosis nodules in the lower posterior compartment, but clinical examination may be normal in many patients with deep infiltrating endometriosis [23].

5.2. Imaging

While diagnostic laparoscopy remains the gold standard, it is often not the first line of diagnosis any more, as noninvasive testing for early diagnosis and progression of endometriosis is being preferred [24]. Yet, no imaging method can definitively confirm the diagnosis of endometriosis, being notably inconclusive in case of peritoneal implants [25].

Deep infiltrating endometriosis (DIE) can be investigated through several imaging techniques, including transvaginal sonography (TVS), magnetic resonance imaging (MRI), computerized tomography, rectal endoscopic sonography, and three-dimensional (3D) ultrasound [23].

TVS has gained interest in recent years and is starting to be recommended as the first-line investigation technique in endometriosis because it allows extensive exploration of the pelvis, is widely available, cost efficient, and well tolerated [26,27,28].

TVS has the benefit of a lack of exposure to radiation and is the main method for the evaluation of adnexal masses, but remains limited for the diagnosis of other kinds of endometriosis. Endometriomas have distinct characteristics on ultrasound: unilocular cysts, most often of homogenous “ground glass” appearance. The identification of an endometrioma should alert the clinician to the possibility of moderate-to-advanced stage disease. An important exception is postmenopausal women, in whom ovarian cysts with a “ground glass” appearance are associated with a 44% risk of malignancy. In addition, TVS may have a role in assessing disease involving the bladder and rectum [29].

Computed tomography (CT) plays a major role in the diagnosis of bowel endometriosis in the presence of colon distension. Genitourinary tract involvement should be taken into consideration in case of hydronephrosis or hydroureter diagnosed on CT scan, especially in patients with a history of chronic pelvic pain or in patients with a history of endometriosis. Radiation exposure should be taken into consideration [29].

MRI is a noninvasive diagnostic method of DIE that offers the possibility to fully investigate the pelvic cavity with a high accuracy, but increased costs [30]. Nevertheless, MRI has limited indication in the diagnosis of endometriosis. It can confirm the diagnosis of endometrioma in the presence of an adnexal mass when TVS is uncertain. MRI can also be used as an investigation method when involvement of the ureter is suspected, and may be beneficial in the evaluation of anatomy when expanded pelvic adhesions are suspected [29].

Sonovaginography using saline solution (saline contrast sonovaginography (SCSV)) or gel infusion sonovaginography is a new diagnostic method in DIE. First described by Dessole et al., it consists of TVS combined with the introduction of saline solution or gel infusion into the vagina, which offers the benefit of a more complete view of the vaginal walls and fornix, pouch Douglas, uterosacral ligaments, and rectovaginal septum [22]. The data available in literature is limited, with only a few reports from Brazil, Italy, Romania, and Australia, but the methods seems beneficial in the diagnosis of posterior deep infiltrating endometriosis. Up to date, no studies have reported its use in postmenopausal patients [22,31,32,33].

The role of double-contrast barium enema (DCBE) in the evaluation of rectovaginal endometriosis is controversial. Some studies have reported high accuracy in predicting the need for intestinal surgery in endometriosis cases. The superiority of DCBE over rectal ultrasound or MRI is not well established, the results reported in literature being scarce and contradictory. However, certain studies have demonstrated a lower sensitivity of DCBE for rectovaginal disease. DCBE does not allow the examination of the entire intestinal wall thickness and does not provide information regarding the depth of infiltration, but may provide useful information for preoperative planning when severe disease is suspected [29].

5.3. Biomarkers

To this date, no specific markers for the diagnosis of endometriosis have been identified. A change in levels of proteins, microRNAs, and other markers corresponding to a disease state could be the basis for identifying novel biomarkers. Endometriosis patients often show modified ranges of CA-125 (Cancer Antigen 125), cytokines, angiogenic and growth factors compared with normal women, but all of these biomarkers are frequently encountered in various other pathologies and are not specific enough for diagnosing endometriosis. A combination of biomarkers may improve the sensitivity and specificity over single biomarker measurements. Moreover, stem cell, proteomic, and genomic studies could contribute to the development of new high-sensitivity biomarkers in the diagnosis of endometriosis in the future [24].

Many authors have studied the role of biomarkers for diagnosis of endometriosis and concluded that, to date, endometrial tissue, menstrual or uterine fluids, and immunologic markers in blood or urine are not recommended for clinical use for diagnosis of endometriosis [24].

Regarding the differential diagnosis between endometriomas and malignant ovarian tumors in postmenopausal patients, we have not found any information in the literature that supports the use of any novel tests, such as OVA1 (Ovarian Malignancy Algorithm), ROMA (risk of ovarian malignancy algorithm), circulating miRs, etc. Despite the potential clinical utility of these biomarkers in the diagnosis of malignant ovarian tumors in premenopausal patients, the costs implied, the lack of easy availability, and the decreased incidence of endometriomas in older patients make the usefulness of novel biomarkers difficult to assess [34,35,36].

5.4. Minimally Invasive Surgery: Laparoscopy and Robot Assistance

Because of the lack of specific and efficient noninvasive tests for endometriosis, there is often a significant delay in diagnosis of this disease, especially in older patients. The gold standard for the diagnosis of endometriosis remains visual inspection by laparoscopy, preferably with histological confirmation. A positive histological examination confirms the diagnosis, but negative histology does not exclude it, in the presence of pathognomonic lesions [23].

Whether histology should be obtained if peritoneal disease alone is present is controversial: a visual inspection of the pelvis should be enough, but histological confirmation of at least one lesion is ideal. In some cases, histology should be obtained to identify endometriosis and to exclude malignant disease. For example, in ovarian endometriomas (>3 cm in diameter) and in deeply infiltrating disease, a histological confirmation to exclude a rare instance of malignancy is necessary [37].

Laparoscopy is used for the diagnosis and treatment of DIE and serves to eradicate all visible endometriosis implants, especially in postmenopausal patients due to the risk of malignant transformation. Several studies have shown a significant improvement of symptoms and a decreased risk of malignancy in postmenopausal women after complete resection of all visible lesions. Precise preoperative imaging may help guide surgical therapeutic approaches and aid to obtain the best postoperative results [23]. In the last years, the da Vinci surgical system started to be used in the diagnosis and treatment of endometriosis. Three-dimensional (3D) vision offers the advantage of improved depth perception and accuracy in the performance of robotic surgery, particularly for complex surgical tasks such as identifying suspected implants. However, the robotic platform has the distinct disadvantage of offering only a unidirectional view within the abdominal cavity. Authors recommend for the first instance to undertake a diagnostic laparoscopy to exclude a suspected lesion of endometriosis in the upper abdomen, liver, diaphragm, and appendix before using the da Vinci robotic system in the pelvis. Another disadvantage is the loss of haptic feedback to identify fibrotic lesions which are characteristic of deeply infiltrating disease. However, the da Vinci robot may offer improved ease by avoiding hand and more instinctual movement of the wristed instruments in the treatment of endometriosis. The cost related to the procedure also make it unavailable at a large scale [29].

6. Management

6.1. The Impact of Hormone Replacement Therapy in Women with a History of Endometriosis

The recently published guidelines on menopause management have no statements of endometriosis symptoms [38]. The use of HRT raises concerns about disease reactivation and recurrence of pain and need for surgical treatment, and even malignant transformation of residual endometriosis. The risk of recurrence with HRT is considered to be linked to residual disease after surgery. The data regarding hormone therapy regimens is scarce. Continuous combined estrogen–progesterone treatment or tibolone, in patients with or without hysterectomy, is considered to carry a lower risk of disease recurrence, compared with estrogen-only regimens, but larger studies are required in order to prove the safety and efficacy. Management of potential recurrence is best monitored by awareness of the possibility of symptom recurrence. Patients with contraindication or who refuse hormonal treatment should be offered alternative pharmacological treatment for menopausal symptoms and for skeletal protection, if indicated. Herbal products should be avoided as some may contain estrogenic compounds and their efficacy is uncertain [39,40,41]. The risk of malignant transformation of endometriosis in women with a history of endometriosis who received HRT remains a matter of debate. Long-term follow-up studies are needed to evaluate the risk of an adverse outcome. Further studies are mandatory in order to determine the optimal management of menopause in women with endometriosis [15].

6.2. The Management of De Novo Endometriosis in Postmenopausal Patients and Pain Management

“De novo” endometriosis appears especially after unopposed estrogen therapy or obesity, which has an additional effect for increasing the risk of endometriosis development.

Postmenopausal women with symptomatic endometriosis should be managed surgically with removal of all visible endometriotic tissue because of the higher risk of recurrence and the risk of malignancy [41]. A similar approach is recommended by current ESHRE (European Society of Human Reproduction and Embryology) recommendations. Medical therapy can be used in case of pain recurrence after surgery or if surgery is contraindicated. Co-morbidities represent an additional risk to contraindicate surgery and include advanced age or pelvic adhesions from previous surgery [38,41]. Approximately 12% of all endometriosis cases will finally require a hysterectomy with or without oophorectomy [42,43]. To prevent recurrences, to restore bowel, urinary, or sexual function or to alleviate pain it is now recommended to remove all the implants [38].

Progesterone administration (oral or intrauterine system) has been proposed as a reliable alternative treatment in patients with contraindication for surgery, but, up to date, no extensive data is available and further studies are needed regarding progesterone use in postmenopausal endometriosis [44,45].

Aromatase inhibitors act by decreasing extra-ovarian estrogen production and by blocking the feed-forward stimulation loop between inflammation and aromatase within endometriosis lesions. Only six case reports of aromatase inhibitors administration in postmenopausal patients with a history of endometriosis have been published so far. In 1998, Kayama presented a 57-year-old patient who had presented with recurrent endometriosis with a painful vaginal polypoid mass. The use of Anastrozole reduced the volume of the vaginal mass. Other studies concluded that Letrozole has a similar efficacy to Anastrozole [46,47,48]. The most important risk of this treatment is osteoporosis and related fractures. Aromatase inhibitors impair bone mineral density and need to be associated with bisphosphonate therapy.

7. Tamoxifen and Postmenopausal Endometriosis

Tamoxifen represents a hormonal substitution therapy used in postmenopausal women with breast cancer. Tamoxifen has antiestrogenic effects on breast tissues but promotes endometriosis through unknown mechanisms. In 1993, the first case of tamoxifen-related endometriosis was reported in a woman who received tamoxifen for 2 years due to breast cancer [49]. In the next year, it was reported another case of operated breast cancer and adjuvant tamoxifen [50]. During the next years, many authors reported cases of ovarian and endometrioid carcinoma in the women who had used tamoxifen [51,52,53,54]. Considering that there is no significant statistical evidence, the relation between tamoxifen and malignant transformation may be coincidental [43].

8.

Risk of Malignant Transformation

The possible transformation of endometriosis lesions into malignant lesions and their dissemination in the ovaries, bowel, and even lungs has been described. The risk of malignant transformation of endometrioma into an ovarian cancer is estimated at 2% or 3% [41,55], and may be higher in patients receiving estrogen therapy. Furthermore, patients with endometriosis have an increased risk of other malignancies, apart from ovarian cancer [41].

Differential diagnosis of benign from malignant tumors in postmenopausal women is difficult. We must take into account that some endometriosis lesions may have a similar appearance to malignant disease and can cause local and distant metastases and can infiltrate adjacent tissues and organs. Age is an important risk factor for many malignancies, thus it may be questioned whether the postmenopausal endometriosis increases the risk for malignancy [41].

In 1997, Brinton et al. showed that patients with endometriosis seem to have an increased overall cancer risk [56]. Some authors indicate an increased risk of ovarian cancer, calculated to be around 35% for clear cell carcinoma and 19% for endometrioid type carcinoma in women with endometriosis [57].

On the other hand, Somigliana et al. concluded that there is evidence to support that endometriosis should be considered a medical condition associated with a clinically relevant risk of any specific cancer [58].

Regarding the relationship between endometriosis and breast cancer, Bertelsen et al. published a study which followed around 115,000 Danish women over a period of 30 years. Authors concluded that the risk for breast cancer increased with age (<40 years) at diagnosis of endometriosis and it is around 0.97%. The increased risk associated with endometriosis among postmenopausal women may be due to common risk factors between postmenopausal endometriosis and breast cancer or an altered endogenous estrogen [59].

Because endometriosis and ovarian malignancy have some common risk factors, including low parity rate, infertility, late childbearing age, and short duration of oral contraceptive use, in clinical practice is very difficult to discriminate a benign from a malignant tumor in postmenopausal women [60].

In postmenopausal women who underwent surgery for endometriosis, hormonal therapy remains controversial. Unopposed estrogen stimulation is associated with an increased risk of endometrial cancer. Some studies show that exogenous estrogens are increasing the risk of malignancy transformation of endometriosis lesions. In a retrospective study which followed 31 women with cancer developing from endometriosis, Zanetta et al. concluded that prevalence of endometriosis associated with co-existing risk factors (obesity and unopposed estrogen therapy) represents a significant risk factor for the development of cancer in endometriotic lesions [61].

The indication for initiating hormone therapy in women with endometriosis must be carefully evaluated. In premenopausal women who underwent total hysterectomy and bilateral salpingo-oophorectomy due to endometriosis, the benefits of hormone therapy outweigh the risks. Postmenopausal hormone therapy may increase the risk of malignant transformation or recurrence of endometriosis [41,62]. More data are needed to confirm this.

9. Extrapelvic Endometriosis

Extrapelvic endometriosis is a rare clinical condition in postmenopausal women. It affects a slightly older population due to the fact that it takes several years for pelvic endometriosis to metastasize outside the pelvis. Statistical data regarding menopausal patients are limited. The most common location of extrapelvic endometriosis is the gastrointestinal tract, followed by the urinary system. Bladder and ureteral endometriosis are the most common sites for urinary tract involvement [63]. Regarding the gastrointestinal tract, the sigmoid colon is the most commonly involved, followed by the rectum, ileum, appendix, and caecum [64,65]. Extremely rare locations that have been reported include the gallbladder, the Meckel diverticulum, stomach, and endometriosis cysts of the pancreas and liver [63].

Flyckt et al. presented a 59-year-old woman with a periaortic mass with ureteral obstruction. A computed tomography was performed, and a surgical management was necessary to resect the mass. The pathology exam confirmed endometriosis invasion of the inferior vena cava [66].

9.1. Gastrointestinal Tract Endometriosis

In postmenopausal women with low estrogen levels, a vascular transport or metaplasia of intestinal tissue should be considered for the etiology of gastrointestinal tract endometriosis [65]. The intestinal involvement in endometriosis after menopause is a rare phenomenon and it has been described in literature only in case reports ().

Sigmoid colon endometriosis—macroscopic aspect of the piece after laparoscopic resection using a circular stapler (personal collection, L. Pirtea).

Snyder et al. presented the case of a woman with iron-deficiency anemia, who underwent total hysterectomy with bilateral salpingo-oophorectomy. During the surgical procedure, an endometrial implant at the hepatic flexure was discovered, a rare location for endometriosis. The patient was treated with conjugated estrogen–bazedoxifen to antagonize the effects of estrogen. No evidence of lesion was found at colonoscopy after five months of therapy [11].

Popoutchi reported a rare case of postmenopausal intestinal endometriosis simulating a malignant lesion in a woman who previously underwent hysterectomy with bilateral salpingo-oophorectomy, with no hormone replacement treatment. She was treated by rectosigmoidectomy with colostomy [65].

It is difficult to diagnose bowel endometriosis by colonoscopy because most cases do not infiltrate beyond the serosa and very few infiltrate the mucosa [67]. Deep endometriosis is a very complicated disease to diagnose and treat, especially in older patients [43,68].

Jones et al. reported a case of a surgical menopause for deep rectovaginal endometriosis, with estrogen replacement therapy. A polyp was detected on colonoscopy and the biopsy confirmed a malignant transformation of endometriosis to adenocarcinoma [69].

9.2. Urinary Tract Endometriosis

Urinary tract endometriosis is an uncommon pathology and a silent cause of monolateral or bilateral kidney dysfunction. The diagnosis of urinary tract endometriosis is difficult since the disease is associated with nonspecific symptoms, regardless of the hormonal status [70] ().

Urinary tract endometriosis—laparoscopic resection of a bladder endometriosis nodule infiltrating the bladder mucosa (personal collection, L. Pirtea).

A few case reports have been published regarding bladder endometriosis in postmenopausal women. Stewart reported a case of bladder endometriosis extending into the bowel in a postmenopausal woman. He concluded that it was due to reactivation of the endometrial implants under exogenous estrogen stimulation [71]. Also, a case of a 68-year-old postmenopausal woman, with no exogenous estrogen therapy, with an abnormal mass of the bladder that turned out to be an endometriosis lesion, was reported. This case suggests that endometriosis may persist even after years of a hormonally castrated state [72].

10. Conclusions

The paradigm shift from the belief that endometriosis only affects women of reproductive age has drawn attention to endometriosis in both premenarchal and postmenopausal patients. Despite its relatively low incidence, physicians should consider endometriosis in cases of unclear pelvic pain in postmenopausal patients, even if the patient has no prior history of endometriosis lesions.

Postmenopausal endometriosis seems to expose the patient to a higher risk of malignant transformation. Due to the lack of high-quality studies, it remains unclear how to advise women with a history of endometriosis regarding the management of menopausal symptoms. The absolute risk of disease recurrence and malignant transformation cannot be quantified, and the impact of HRT use on these outcomes is not known. Multicenter randomized trials or large observational studies are urgently needed to inform clinicians and patients alike.

Author Contributions

L.B., C.S. and S.B. were responsible for drafting the article, L.B. and O.B. performed the data collection, data analysis and contributed to the interpretation of the results. L.B., P.P. and G.D. participated in the conception and the design of the study. L.P. and C.S. were responsible for the critical revision of the article and approved the final version to be published. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.

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Endometriosis in Menopause—Renewed Attention on a Controversial Disease

Diagnostics (Basel). 2020 Mar; 10(3): 134.

Paul Pirtea

2Department of Ob Gyn and Reproductive Medicine, Hopital Foch—Faculté de Medicine Paris Ouest (UVSQ), 92151 Suresnes, France; [email protected]

2Department of Ob Gyn and Reproductive Medicine, Hopital Foch—Faculté de Medicine Paris Ouest (UVSQ), 92151 Suresnes, France; [email protected]

Received 2020 Jan 13; Accepted 2020 Feb 27.

Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).This article has been cited by other articles in PMC.

Abstract

Endometriosis, an estrogen-dependent inflammatory disease characterized by the ectopic presence of endometrial tissue, has been the topic of renewed research and debate in recent years. The paradigm shift from the belief that endometriosis only affects women of reproductive age has drawn attention to endometriosis in both premenarchal and postmenopausal patients. There is still scarce information in literature regarding postmenopausal endometriosis, the mostly studied and reported being the prevalence in postmenopausal women. Yet, other important issues also need to be addressed concerning diagnosis, pathophysiology, and management. We aimed at summarizing the currently available data in literature in order to provide a concise and precise update regarding information available on postmenopausal endometriosis.

Keywords: endometriosis, menopause, diagnosis, management, malignancy

1. Introduction

The concept that endometriosis is a disease that only affects women of reproductive age has prevailed since 1942, when the first case of endometriosis in a postmenopausal patient was reported by Edgar Haydon [1].

In spite of this early report, endometriosis has also been described in premenarchal patients and is a common occurrence in adolescents [2,3,4].

The recurrence of endometriosis lesions in patients with a prior diagnosis of endometriosis during the premenopausal period or the de novo appearance of endometriosis in postmenopausal patients with no prior history of endometriosis-related complaints has been however well documented in numerous case series, case reports, and retrospective studies [5,6,7,8,9].

The management of endometriosis in postmenopause and hormone replacement therapy (HRT) in patients with a history of endometriosis remains controversial.

2. Prevalence

The incidence of postmenopausal endometriosis reported in literature is of approximately 2–5%. It commonly represents a side effect of HRT, rarely occurring in patients without a history of HRT or Tamoxifen treatment [10]. In a few cases, postmenopausal endometriosis has been described in women who had no history of endometriosis on imaging or surgery prior to menopause [11].

In order to evaluate the prevalence of postmenopausal endometriosis, Haas et al. performed a retrospective epidemiological study on 42,079 women admitted for surgical treatment with histologically confirmed endometriosis. Patients were sorted in 5 years age groups and also in premenopausal, perimenopausal, and postmenopausal subgroups. The results showed that 33,814 patients (80.36%) were in the premenopausal group (age 0–45 years), with 23 patients (0.05%) being younger than 15 years; of the remaining patients, 7191 (17.09%) were in the perimenopausal (45–55 years), and 1074 patients (2.55%) in the postmenopausal group, respectively [6].

3. Pathophysiology

Endometriosis is an estrogen-dependent inflammatory disease characterized by the presence of ectopic endometrial tissue. The pathogenesis of endometriosis remains enigmatic [12].

Postmenopausal endometriosis is considered to have an even more complex pathophysiology than premenopausal endometriosis. It is still unclear whether this represents a recurrence or continuation of a previous disease or a de novo condition. Excess estrogen, in general, represents a promoting factor for endometriosis. The arrest of estrogen production at the level of the ovaries at the time of menopause is counterbalanced by peripheral estrogen production from conversion of androgens (especially in the adipose tissue and skin). The leading estrogen found in these patients is estrone.

An attractive theory regarding the pathogenic mechanism of postmenopausal endometriosis involves the “estrogen threshold”, i.e., when a certain estrogen level is reached or surpassed in postmenopausal patients it activates undetected or “transient” foci of endometriosis.

In addition to the peripheral estrogen production, a high circulating level of estrogen may be of external source, especially in the form of phytoestrogens and HRT. Phytoestrogens appear to exert estrogenic effects on the uterus, breast, and pituitary and could also support the growth of endometriotic lesions [13,14,15].

Despite the fact that postmenopausal endometriosis has the same immunochemical profile as premenopausal endometriosis and has the potential to reactivate under estrogen stimulation, endometriosis lesions in the postmenopausal period seem to be less common, less extensive, and less active in most cases [16].

4. Symptomatology

The clinical presentation of endometriosis in menopausal patients is unspecific, such as pelvic pain, ovarian cysts, or intestinal symptoms. Given the age of the patients, they are often suspected of a neoplastic process. As a general consideration, all postmenopausal patients should be evaluated for malignancy if a new suspicious structure is found on ultrasound examination.

In menopausal women with a history of endometriosis, the drop in estrogen levels after menopause relieves the endometriosis-related symptoms but generates specific menopausal ones, such as mood swings, hot flushes, vaginal atrophy, and night sweats [5,17]. The clinical grim reality is that the severity of the disease is not necessarily reflected in the degree of discomfort. Commonly, the complaints of pelvic pain underestimate the disease’s severity in both premenopausal and postmenopausal endometriosis.

5. Diagnosis

Despite intensive research conducted in the last decades, endometriosis remains a disease with a delayed diagnosis, especially in older patients. This results from the lack of noninvasive tools available for early stage diagnosis. For many years, there has been a long-standing myth that endometriosis is a disease that affects only adult women of reproductive age. However, in recent years, focus has turned to the diagnosis of endometriosis in postmenopausal patients, given that the onset of pain can start after the onset of menopause, with reports of endometriosis occurring even in 80-year-old patients [1,5].

The ovaries are the most common location of endometriotic lesions in postmenopausal patients (79.2% of cases) [18].

Distinction between endometriosis lesions and cancer is complicated by the fact that some of the risk factors are similar, such as low parity rate, infertility, late childbearing age, and a short duration of oral contraceptive use [19].

Currently, laparoscopy and biopsy for histological confirmation of suspicious lesions is the gold standard for diagnosis of endometriosis, irrespective of age. Laparoscopy, the standard technique for inspecting the pelvis, can provide simultaneous diagnosis and treatment of lesions. Additional tools are needed for a noninvasive diagnostic and classification. To this date, no serum marker or test is available for reliably diagnosing endometriosis [20,21]. Regarding imaging investigations, MRI and ultrasound are important, but findings are more difficult to interpret in menopausal patients than in younger patients due to the higher suspicion for neoplastic lesions and the polymorphic aspect of endometriosis.

5.1. Clinical Examination

The patient’s medical history, clinical examination, or preoperative symptoms have a limited role in determining the extent of endometriosis lesions as there is no direct relationship between symptoms and the anatomic-surgical characteristics of endometriotic lesions [22]. Also, there is usually a discrepancy between the severity of symptoms and the extent of lesions with many patients whose severe lesions remain asymptomatic. This is an important factor contributing to a delay of approximately 6 to 8 years from onset of symptoms to diagnosis in premenopausal and postmenopausal patients alike [23].

Pelvic vaginal and rectal examination is useful in identifying endometriosis nodules in the lower posterior compartment, but clinical examination may be normal in many patients with deep infiltrating endometriosis [23].

5.2. Imaging

While diagnostic laparoscopy remains the gold standard, it is often not the first line of diagnosis any more, as noninvasive testing for early diagnosis and progression of endometriosis is being preferred [24]. Yet, no imaging method can definitively confirm the diagnosis of endometriosis, being notably inconclusive in case of peritoneal implants [25].

Deep infiltrating endometriosis (DIE) can be investigated through several imaging techniques, including transvaginal sonography (TVS), magnetic resonance imaging (MRI), computerized tomography, rectal endoscopic sonography, and three-dimensional (3D) ultrasound [23].

TVS has gained interest in recent years and is starting to be recommended as the first-line investigation technique in endometriosis because it allows extensive exploration of the pelvis, is widely available, cost efficient, and well tolerated [26,27,28].

TVS has the benefit of a lack of exposure to radiation and is the main method for the evaluation of adnexal masses, but remains limited for the diagnosis of other kinds of endometriosis. Endometriomas have distinct characteristics on ultrasound: unilocular cysts, most often of homogenous “ground glass” appearance. The identification of an endometrioma should alert the clinician to the possibility of moderate-to-advanced stage disease. An important exception is postmenopausal women, in whom ovarian cysts with a “ground glass” appearance are associated with a 44% risk of malignancy. In addition, TVS may have a role in assessing disease involving the bladder and rectum [29].

Computed tomography (CT) plays a major role in the diagnosis of bowel endometriosis in the presence of colon distension. Genitourinary tract involvement should be taken into consideration in case of hydronephrosis or hydroureter diagnosed on CT scan, especially in patients with a history of chronic pelvic pain or in patients with a history of endometriosis. Radiation exposure should be taken into consideration [29].

MRI is a noninvasive diagnostic method of DIE that offers the possibility to fully investigate the pelvic cavity with a high accuracy, but increased costs [30]. Nevertheless, MRI has limited indication in the diagnosis of endometriosis. It can confirm the diagnosis of endometrioma in the presence of an adnexal mass when TVS is uncertain. MRI can also be used as an investigation method when involvement of the ureter is suspected, and may be beneficial in the evaluation of anatomy when expanded pelvic adhesions are suspected [29].

Sonovaginography using saline solution (saline contrast sonovaginography (SCSV)) or gel infusion sonovaginography is a new diagnostic method in DIE. First described by Dessole et al., it consists of TVS combined with the introduction of saline solution or gel infusion into the vagina, which offers the benefit of a more complete view of the vaginal walls and fornix, pouch Douglas, uterosacral ligaments, and rectovaginal septum [22]. The data available in literature is limited, with only a few reports from Brazil, Italy, Romania, and Australia, but the methods seems beneficial in the diagnosis of posterior deep infiltrating endometriosis. Up to date, no studies have reported its use in postmenopausal patients [22,31,32,33].

The role of double-contrast barium enema (DCBE) in the evaluation of rectovaginal endometriosis is controversial. Some studies have reported high accuracy in predicting the need for intestinal surgery in endometriosis cases. The superiority of DCBE over rectal ultrasound or MRI is not well established, the results reported in literature being scarce and contradictory. However, certain studies have demonstrated a lower sensitivity of DCBE for rectovaginal disease. DCBE does not allow the examination of the entire intestinal wall thickness and does not provide information regarding the depth of infiltration, but may provide useful information for preoperative planning when severe disease is suspected [29].

5.3. Biomarkers

To this date, no specific markers for the diagnosis of endometriosis have been identified. A change in levels of proteins, microRNAs, and other markers corresponding to a disease state could be the basis for identifying novel biomarkers. Endometriosis patients often show modified ranges of CA-125 (Cancer Antigen 125), cytokines, angiogenic and growth factors compared with normal women, but all of these biomarkers are frequently encountered in various other pathologies and are not specific enough for diagnosing endometriosis. A combination of biomarkers may improve the sensitivity and specificity over single biomarker measurements. Moreover, stem cell, proteomic, and genomic studies could contribute to the development of new high-sensitivity biomarkers in the diagnosis of endometriosis in the future [24].

Many authors have studied the role of biomarkers for diagnosis of endometriosis and concluded that, to date, endometrial tissue, menstrual or uterine fluids, and immunologic markers in blood or urine are not recommended for clinical use for diagnosis of endometriosis [24].

Regarding the differential diagnosis between endometriomas and malignant ovarian tumors in postmenopausal patients, we have not found any information in the literature that supports the use of any novel tests, such as OVA1 (Ovarian Malignancy Algorithm), ROMA (risk of ovarian malignancy algorithm), circulating miRs, etc. Despite the potential clinical utility of these biomarkers in the diagnosis of malignant ovarian tumors in premenopausal patients, the costs implied, the lack of easy availability, and the decreased incidence of endometriomas in older patients make the usefulness of novel biomarkers difficult to assess [34,35,36].

5.4. Minimally Invasive Surgery: Laparoscopy and Robot Assistance

Because of the lack of specific and efficient noninvasive tests for endometriosis, there is often a significant delay in diagnosis of this disease, especially in older patients. The gold standard for the diagnosis of endometriosis remains visual inspection by laparoscopy, preferably with histological confirmation. A positive histological examination confirms the diagnosis, but negative histology does not exclude it, in the presence of pathognomonic lesions [23].

Whether histology should be obtained if peritoneal disease alone is present is controversial: a visual inspection of the pelvis should be enough, but histological confirmation of at least one lesion is ideal. In some cases, histology should be obtained to identify endometriosis and to exclude malignant disease. For example, in ovarian endometriomas (>3 cm in diameter) and in deeply infiltrating disease, a histological confirmation to exclude a rare instance of malignancy is necessary [37].

Laparoscopy is used for the diagnosis and treatment of DIE and serves to eradicate all visible endometriosis implants, especially in postmenopausal patients due to the risk of malignant transformation. Several studies have shown a significant improvement of symptoms and a decreased risk of malignancy in postmenopausal women after complete resection of all visible lesions. Precise preoperative imaging may help guide surgical therapeutic approaches and aid to obtain the best postoperative results [23]. In the last years, the da Vinci surgical system started to be used in the diagnosis and treatment of endometriosis. Three-dimensional (3D) vision offers the advantage of improved depth perception and accuracy in the performance of robotic surgery, particularly for complex surgical tasks such as identifying suspected implants. However, the robotic platform has the distinct disadvantage of offering only a unidirectional view within the abdominal cavity. Authors recommend for the first instance to undertake a diagnostic laparoscopy to exclude a suspected lesion of endometriosis in the upper abdomen, liver, diaphragm, and appendix before using the da Vinci robotic system in the pelvis. Another disadvantage is the loss of haptic feedback to identify fibrotic lesions which are characteristic of deeply infiltrating disease. However, the da Vinci robot may offer improved ease by avoiding hand and more instinctual movement of the wristed instruments in the treatment of endometriosis. The cost related to the procedure also make it unavailable at a large scale [29].

6. Management

6.1. The Impact of Hormone Replacement Therapy in Women with a History of Endometriosis

The recently published guidelines on menopause management have no statements of endometriosis symptoms [38]. The use of HRT raises concerns about disease reactivation and recurrence of pain and need for surgical treatment, and even malignant transformation of residual endometriosis. The risk of recurrence with HRT is considered to be linked to residual disease after surgery. The data regarding hormone therapy regimens is scarce. Continuous combined estrogen–progesterone treatment or tibolone, in patients with or without hysterectomy, is considered to carry a lower risk of disease recurrence, compared with estrogen-only regimens, but larger studies are required in order to prove the safety and efficacy. Management of potential recurrence is best monitored by awareness of the possibility of symptom recurrence. Patients with contraindication or who refuse hormonal treatment should be offered alternative pharmacological treatment for menopausal symptoms and for skeletal protection, if indicated. Herbal products should be avoided as some may contain estrogenic compounds and their efficacy is uncertain [39,40,41]. The risk of malignant transformation of endometriosis in women with a history of endometriosis who received HRT remains a matter of debate. Long-term follow-up studies are needed to evaluate the risk of an adverse outcome. Further studies are mandatory in order to determine the optimal management of menopause in women with endometriosis [15].

6.2. The Management of De Novo Endometriosis in Postmenopausal Patients and Pain Management

“De novo” endometriosis appears especially after unopposed estrogen therapy or obesity, which has an additional effect for increasing the risk of endometriosis development.

Postmenopausal women with symptomatic endometriosis should be managed surgically with removal of all visible endometriotic tissue because of the higher risk of recurrence and the risk of malignancy [41]. A similar approach is recommended by current ESHRE (European Society of Human Reproduction and Embryology) recommendations. Medical therapy can be used in case of pain recurrence after surgery or if surgery is contraindicated. Co-morbidities represent an additional risk to contraindicate surgery and include advanced age or pelvic adhesions from previous surgery [38,41]. Approximately 12% of all endometriosis cases will finally require a hysterectomy with or without oophorectomy [42,43]. To prevent recurrences, to restore bowel, urinary, or sexual function or to alleviate pain it is now recommended to remove all the implants [38].

Progesterone administration (oral or intrauterine system) has been proposed as a reliable alternative treatment in patients with contraindication for surgery, but, up to date, no extensive data is available and further studies are needed regarding progesterone use in postmenopausal endometriosis [44,45].

Aromatase inhibitors act by decreasing extra-ovarian estrogen production and by blocking the feed-forward stimulation loop between inflammation and aromatase within endometriosis lesions. Only six case reports of aromatase inhibitors administration in postmenopausal patients with a history of endometriosis have been published so far. In 1998, Kayama presented a 57-year-old patient who had presented with recurrent endometriosis with a painful vaginal polypoid mass. The use of Anastrozole reduced the volume of the vaginal mass. Other studies concluded that Letrozole has a similar efficacy to Anastrozole [46,47,48]. The most important risk of this treatment is osteoporosis and related fractures. Aromatase inhibitors impair bone mineral density and need to be associated with bisphosphonate therapy.

7. Tamoxifen and Postmenopausal Endometriosis

Tamoxifen represents a hormonal substitution therapy used in postmenopausal women with breast cancer. Tamoxifen has antiestrogenic effects on breast tissues but promotes endometriosis through unknown mechanisms. In 1993, the first case of tamoxifen-related endometriosis was reported in a woman who received tamoxifen for 2 years due to breast cancer [49]. In the next year, it was reported another case of operated breast cancer and adjuvant tamoxifen [50]. During the next years, many authors reported cases of ovarian and endometrioid carcinoma in the women who had used tamoxifen [51,52,53,54]. Considering that there is no significant statistical evidence, the relation between tamoxifen and malignant transformation may be coincidental [43].

8. Risk of Malignant Transformation

The possible transformation of endometriosis lesions into malignant lesions and their dissemination in the ovaries, bowel, and even lungs has been described. The risk of malignant transformation of endometrioma into an ovarian cancer is estimated at 2% or 3% [41,55], and may be higher in patients receiving estrogen therapy. Furthermore, patients with endometriosis have an increased risk of other malignancies, apart from ovarian cancer [41].

Differential diagnosis of benign from malignant tumors in postmenopausal women is difficult. We must take into account that some endometriosis lesions may have a similar appearance to malignant disease and can cause local and distant metastases and can infiltrate adjacent tissues and organs. Age is an important risk factor for many malignancies, thus it may be questioned whether the postmenopausal endometriosis increases the risk for malignancy [41].

In 1997, Brinton et al. showed that patients with endometriosis seem to have an increased overall cancer risk [56]. Some authors indicate an increased risk of ovarian cancer, calculated to be around 35% for clear cell carcinoma and 19% for endometrioid type carcinoma in women with endometriosis [57].

On the other hand, Somigliana et al. concluded that there is evidence to support that endometriosis should be considered a medical condition associated with a clinically relevant risk of any specific cancer [58].

Regarding the relationship between endometriosis and breast cancer, Bertelsen et al. published a study which followed around 115,000 Danish women over a period of 30 years. Authors concluded that the risk for breast cancer increased with age (<40 years) at diagnosis of endometriosis and it is around 0.97%. The increased risk associated with endometriosis among postmenopausal women may be due to common risk factors between postmenopausal endometriosis and breast cancer or an altered endogenous estrogen [59].

Because endometriosis and ovarian malignancy have some common risk factors, including low parity rate, infertility, late childbearing age, and short duration of oral contraceptive use, in clinical practice is very difficult to discriminate a benign from a malignant tumor in postmenopausal women [60].

In postmenopausal women who underwent surgery for endometriosis, hormonal therapy remains controversial. Unopposed estrogen stimulation is associated with an increased risk of endometrial cancer. Some studies show that exogenous estrogens are increasing the risk of malignancy transformation of endometriosis lesions. In a retrospective study which followed 31 women with cancer developing from endometriosis, Zanetta et al. concluded that prevalence of endometriosis associated with co-existing risk factors (obesity and unopposed estrogen therapy) represents a significant risk factor for the development of cancer in endometriotic lesions [61].

The indication for initiating hormone therapy in women with endometriosis must be carefully evaluated. In premenopausal women who underwent total hysterectomy and bilateral salpingo-oophorectomy due to endometriosis, the benefits of hormone therapy outweigh the risks. Postmenopausal hormone therapy may increase the risk of malignant transformation or recurrence of endometriosis [41,62]. More data are needed to confirm this.

9. Extrapelvic Endometriosis

Extrapelvic endometriosis is a rare clinical condition in postmenopausal women. It affects a slightly older population due to the fact that it takes several years for pelvic endometriosis to metastasize outside the pelvis. Statistical data regarding menopausal patients are limited. The most common location of extrapelvic endometriosis is the gastrointestinal tract, followed by the urinary system. Bladder and ureteral endometriosis are the most common sites for urinary tract involvement [63]. Regarding the gastrointestinal tract, the sigmoid colon is the most commonly involved, followed by the rectum, ileum, appendix, and caecum [64,65]. Extremely rare locations that have been reported include the gallbladder, the Meckel diverticulum, stomach, and endometriosis cysts of the pancreas and liver [63].

Flyckt et al. presented a 59-year-old woman with a periaortic mass with ureteral obstruction. A computed tomography was performed, and a surgical management was necessary to resect the mass. The pathology exam confirmed endometriosis invasion of the inferior vena cava [66].

9.1. Gastrointestinal Tract Endometriosis

In postmenopausal women with low estrogen levels, a vascular transport or metaplasia of intestinal tissue should be considered for the etiology of gastrointestinal tract endometriosis [65]. The intestinal involvement in endometriosis after menopause is a rare phenomenon and it has been described in literature only in case reports ().

Sigmoid colon endometriosis—macroscopic aspect of the piece after laparoscopic resection using a circular stapler (personal collection, L. Pirtea).

Snyder et al. presented the case of a woman with iron-deficiency anemia, who underwent total hysterectomy with bilateral salpingo-oophorectomy. During the surgical procedure, an endometrial implant at the hepatic flexure was discovered, a rare location for endometriosis. The patient was treated with conjugated estrogen–bazedoxifen to antagonize the effects of estrogen. No evidence of lesion was found at colonoscopy after five months of therapy [11].

Popoutchi reported a rare case of postmenopausal intestinal endometriosis simulating a malignant lesion in a woman who previously underwent hysterectomy with bilateral salpingo-oophorectomy, with no hormone replacement treatment. She was treated by rectosigmoidectomy with colostomy [65].

It is difficult to diagnose bowel endometriosis by colonoscopy because most cases do not infiltrate beyond the serosa and very few infiltrate the mucosa [67]. Deep endometriosis is a very complicated disease to diagnose and treat, especially in older patients [43,68].

Jones et al. reported a case of a surgical menopause for deep rectovaginal endometriosis, with estrogen replacement therapy. A polyp was detected on colonoscopy and the biopsy confirmed a malignant transformation of endometriosis to adenocarcinoma [69].

9.2. Urinary Tract Endometriosis

Urinary tract endometriosis is an uncommon pathology and a silent cause of monolateral or bilateral kidney dysfunction. The diagnosis of urinary tract endometriosis is difficult since the disease is associated with nonspecific symptoms, regardless of the hormonal status [70] ().

Urinary tract endometriosis—laparoscopic resection of a bladder endometriosis nodule infiltrating the bladder mucosa (personal collection, L. Pirtea).

A few case reports have been published regarding bladder endometriosis in postmenopausal women. Stewart reported a case of bladder endometriosis extending into the bowel in a postmenopausal woman. He concluded that it was due to reactivation of the endometrial implants under exogenous estrogen stimulation [71]. Also, a case of a 68-year-old postmenopausal woman, with no exogenous estrogen therapy, with an abnormal mass of the bladder that turned out to be an endometriosis lesion, was reported. This case suggests that endometriosis may persist even after years of a hormonally castrated state [72].

10. Conclusions

The paradigm shift from the belief that endometriosis only affects women of reproductive age has drawn attention to endometriosis in both premenarchal and postmenopausal patients. Despite its relatively low incidence, physicians should consider endometriosis in cases of unclear pelvic pain in postmenopausal patients, even if the patient has no prior history of endometriosis lesions.

Postmenopausal endometriosis seems to expose the patient to a higher risk of malignant transformation. Due to the lack of high-quality studies, it remains unclear how to advise women with a history of endometriosis regarding the management of menopausal symptoms. The absolute risk of disease recurrence and malignant transformation cannot be quantified, and the impact of HRT use on these outcomes is not known. Multicenter randomized trials or large observational studies are urgently needed to inform clinicians and patients alike.

Author Contributions

L.B., C.S. and S.B. were responsible for drafting the article, L.B. and O.B. performed the data collection, data analysis and contributed to the interpretation of the results. L.B., P.P. and G.D. participated in the conception and the design of the study. L.P. and C.S. were responsible for the critical revision of the article and approved the final version to be published. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.

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Postmenopausal endometriosis: An enigma revisited

Endometriosis is a common gynecological disorder associated with infertility and chronic pelvic pain and traditionally been considered as a disease of the premenopausal years.[1] For pelvic disease alone, three clinical forms have been described: superficial implants on the pelvic peritoneum and ovaries, ovarian endometriotic cysts and rectovaginal nodules.[2] Besides pelvic disease, extra pelvic disease has also been reported.[3] Many theories have been proposed to explain the cause of endometriosis, but no single theory is capable of explaining the pathophysiology of endometriosis in its various forms. It has been suggested that the three different presentations of pelvic endometriosis may be caused by three different mechanisms.[4] As no single mechanism has been elucidated for premenopausal disease, it is highly unlikely that one single theory could account for postmenopausal disease.

There are no sensitive markers for the diagnosis of endometriosis, except for diagnostic laparoscopy, which is the gold standard for its diagnosis. It is possible that women in their premenopausal years may have had asymptomatic endometriosis or there could be women who had symptoms, but did not undergo a laparoscopy, and in both these groups, the disease progressed in their postmenopausal years. It is also known that discovery of a lesion in a premenopausal woman does not always guarantee progression of disease in the menopause. And on the other hand, a previous negative laparoscopy does not always mean that there would be no later development of the disease just prior to the menopause. Evidence suggests that postmenopausal endometriosis could have arisen in patients with a premenopausal history of the disease.

Laparoscopic evaluation of chronic pelvic pain in endometriosis has shown poor correlation with symptoms and extent of disease[5] Endometriosis has also been detected laparoscopically in 70% of fertile, asymptomatic, multiparous women in whom a previous diagnosis of endometriosis has not been made based on either symptoms or investigations.[6] Endometriosis once established can persist in the presence of low circulating levels of estrogen as seen in the postmenopausal period. Local estradiol production by the endometriotic lesions drives the disease through autocrine and paracrine effects. If endometriosis does occur in the postmenopausal period, it is less common, is present in smaller volumes and is less active. Yet it has the same immunochemical profile as the disease occurring in premenopausal women and has the potential to reactivate when given the appropriate stimulation.[7]

Postmenopausal disease could be enhanced in the presence of higher circulating levels of estrogen especially in the form of phytoestrogens and hormone therapy (HT). Phytoestrogens have been known to exert estrogenic effects on the uterus, breast and pituitary[8] and support growth of endometriotic deposits.[2] As these are over-the-counter drugs, their use is indiscriminate and could be responsible for perpetuating preexisting premenopausal endometriosis in the postmenopausal period, when used for menopausal symptom relief. This can occur as density of estrogen receptors in endometriotic tissue appears to be unchanged in older patients.

Limited data are available on the effect of type of HT in women with previous endometriosis. Tibolone has been proposed to be a safe treatment in such women. Unopposed estrogen therapy was found to reactivate symptoms of pelvic pain and deep dyspareunia[8,9] after Total Hysterectomy with Bilateral Salpingo (TAH and BSO) for endometriosis.[10] HT immediately after TAH + BSO or 6 weeks after surgery did not change the risk of recurrent pain.

Endometriosis is in some ways similar to malignant disease. It can cause local and distant metastases, attach to, invade and damage adjacent tissues. In 1925, Sampson was the first to describe malignant transformation and reported an incidence of 1%.[11] The risk of malignant transformation of endometriosis deposits is higher in postmenopausal women,[7] especially in women with long-standing history of ovarian endometriosis.[12] Hence, clinicians should be alert to the possibility of endometriosis in any postmenopausal patient with symptoms of the disease. If endometriosis is confirmed on investigation, a careful follow-up of such women on a long-term basis is necessary for future adverse outcomes. Obesity and unopposed estrogen are 2 risk factors, which have an additional effect for significantly increasing the risk of cancer in endometriosis,[3] hence combined HT is recommended. The risk of extra ovarian malignant transformation is low, the most common site being the vagina.[13]

The treatment of postmenopausal endometriosis that was first reported in 1950 is primarily surgical, but medical treatment may be a future option. Use of GnRh analogues, danazol and progesterone, appears to be ineffective in postmenopausal endometriosis.[14] AI’s may be a new promising method, which could potentially improve symptoms and treat these patients either as first-line treatment when surgery is contraindicated or as a second-line treatment for recurrences following surgical treatment. Al’s could significantly impair bone mineral density and increase the rate of bone fractures, hence need to be supplemented with bis-phosphonate therapy. HT has more benefits than risks in women who are premenopausal at the time of radical operation. Unopposed estrogen therapy (ET) following menopause might increase the risk of persistence or reoccurrence of endometriosis. Furthermore, ET may potentially increase the risk of neoplastic transformation of the residual tissue whilst HT may have a lower risk. More data are needed to confirm this. It is important to follow-up all patients operated for endometriosis who have been subsequently prescribed HT, on a long-term basis.

Why Menopause Won’t Cure Endometriosis, Fibroids, or Ovarian Cysts

Fibroids After Menopause

Fibroids are usually noncancerous growths in the uterus that can cause abnormal bleeding, according to UCLA Health. The hormones estrogen and progesterone stimulate their growth. When fibroids are large, they can cause discomfort and pain as well.

RELATED: 10 Things Your Doctor Won’t Tell You About Hysterectomy

You might think that fibroids will shrink or disappear once you’ve gone through menopause because your hormone levels drop dramatically. But that’s not always the case, says Matthew Siedhoff, MD, director of minimally invasive gynecologic surgery at the University of North Carolina at Chapel Hill. “And if a woman chooses hormone replacement therapy (HRT) after menopause, she could still experience bleeding symptoms and even fibroid growth after menopause,” Dr. Siedhoff says.

If your fibroids aren’t causing symptoms after menopause, don’t do anything, Siedhoff advises. But if your fibroids change in size or you start bleeding and are not on hormone replacement therapy, see your doctor to explore the cause.

Symptoms include pelvic pressure similar to period cramps, urgency to urinate when fibroids press on the bladder, and abdominal bloating when fibroids grow large.

If your fibroid symptoms are bothersome after menopause, you should consider surgery options, Siedhoff says. In some cases, interventional radiologists can perform procedures known as embolization that shrink fibroids by cutting off their blood supply, according to the NYU Langone Medical Center Department of Radiology. These procedures are not recommended in menopausal women, though, “because the fibroids have already shrunk as much as they’re going to,” Siedhoff says.

The best option is often surgery because it is the most effective, he says — either a hysterectomy, which removes the uterus, or a myomectomy, which removes just the fibroids, as the University of California San Francisco Medical Center explains.

Polycystic Ovary Syndrome and Menopause

Polycystic ovary syndrome (PCOS) is a hormonal disorder in which a woman’s ovaries produce more androgens, commonly known as male hormones, than she needs. As a result, a woman can have irregular menstrual cycles (or lack them completely), body-hair growth in unwanted places, thinning scalp hair, weight gain, and insulin resistance, according to the Department of Health and Human Services (HHS).

Some of these symptoms, such as excessive body-hair growth and thinning scalp hair, may get worse after menopause.

On the other hand, after menopause you no longer need treatments to bring on your period, says Maryam Siddiqui, MD, an assistant professor of obstetrics and gynecology at University of Chicago Medicine.

However, PCOS puts women at greater risk for cardiovascular disease, diabetes, high blood pressure, and sleep apnea, notes HHS. Aging also increases your risk for these conditions. That’s why as women with PCOS grow older and go through menopause, they need to be even more vigilant about managing risk factors for these other serious health issues, Dr. Siddiqui says.

If you have PCOS, ask your doctor about screening for high cholesterol and diabetes. Also, keep tabs on your blood pressure and weight.

Rare Location and Novel Medical Therapy

We report an uncommon case of deep infiltrating endometriosis of the colon presenting as iron deficiency anemia nine years after hysterectomy with bilateral salpingo-oophorectomy. The endometrial implant was found at the hepatic flexure, an exceedingly rare location for endometriosis invasion with no cases distinctly reported in the literature. Additionally, the presentation of gastrointestinal endometriosis as iron deficiency anemia is not well documented in the literature. Instead of surgery, we prescribed a novel medical therapeutic approach using conjugated estrogen-bazedoxifene to antagonize the proliferative effects of estrogen on endometrial tissue. After five months of therapy and repeat colonoscopy, no evidence of endometrial tissue remained in the hepatic flexure.

1. Introduction

Endometriosis is a common disorder in women of reproductive age occurring in 8–10% [1]. However, endometriosis has not been significantly studied in postmenopausal women. The development of endometriosis after menopause is a rare phenomenon, and it has often been reported in the setting of hormone replacement therapy (HRT) [2] and treatment with tamoxifen [3, 4]. While postmenopausal endometriosis is uncommon, deep infiltrating endometriosis involving the colon in postmenopausal women has been noted only in the case report literature [5–9]. We describe a case of a postmenopausal woman presenting with iron deficiency anemia due to colonic endometrial infiltration and a novel therapeutic approach.

2. Case Report

A 60-year-old Caucasian woman was referred to gastroenterology department due to three years of persistent iron deficiency anemia (IDA) resistant to oral iron supplementation with patient-reported blood in the stool. Her history was significant for endometriosis in early reproductive years and uterine fibroids treated by hysterectomy with bilateral salpingo-oophorectomy nine years before her current presentation. She was given oral estradiol therapy as part of hormone replacement therapy (HRT). She underwent an esophagogastroduodenoscopy (EGD) that was of normal result and a colonoscopy that revealed moderately severe diverticulosis and a nodular ulcerated lesion at the hepatic flexure (Figure 1) that was partially removed by hot snare cauterization (Figure 2). This was not a complete resection and allowed for better tissue sampling. The nodule appeared deeper than what could be visualized by endoscopy and was biopsied multiple times. India ink was used to tattoo the location of the nodule for a follow-up examination.


Histological analysis of the biopsies noted mural endometriosis and adenomatous tissue within the endometrial tissue and surrounding mucosa (Figure 3). The endometrial tissue infiltrated the full thickness of the biopsy specimen, which extended through the submucosa. The presence of endometrial tissue through the depth of the biopsy, extending into the mucosa, is indicative of complete thickness penetration of the colonic wall. Though the patient experienced no other symptoms of endometriosis, deep infiltrating endometriosis was a likely explanation for her IDA. Gynecology was consulted, and the patient’s estradiol therapy was discontinued. Given that the subject had few physical symptoms of her disease but had previously suffered vasomotor symptoms of menopause, medical treatment was an appropriate approach for her condition. A course of conjugated estrogen-bazedoxifene (CE/BZA) (Duavee: 0.45–20 mg, Pfizer, New York, NY) was selected instead of surgery. CE/BZA is commonly used in women with a uterus who desire HRT, as it prevents estrogen from stimulating endometrial tissues using the selective estrogen receptor modulator, bazedoxifene.

Approximately three months after her original visit to gastroenterology department and consultation with hematology, the patient received two intravenous iron infusions one week apart in conjunction with the course of CE/BZA therapy. Follow-up colonoscopy, eight months after the initial colonoscopy and five months of CE/BZA therapy, demonstrated scarring from the initial procedure and no residual nodule at the hepatic flexure (Figure 4). Biopsies taken identified fragments of tubular adenoma without any evidence of remaining endometriosis suggesting complete regression. Follow-up labs revealed normalization of iron studies, anemia, and microcytosis. Iron infusion and complete regression of endometrial tissue and reversal of minor blood loss from associated ulceration are the presumptive explanation for resolution of this patient’s iron deficiency anemia.

3. Discussion

Deep endometriosis (also called deep infiltrating endometriosis) is a form of endometriosis that invades any vital structures such as bowel, ureters, or bladder [10]. Intestinal involvement of endometriosis has been estimated to exist in between 3.8% and 37% of patients with an endometriosis diagnosis [11]. The most common sites of bowel endometriosis are rectum, ileum, appendix, and cecum from most to least prevalent, while some cases of gastric and transverse colonic involvement have been reported [11]. Endometriosis is often difficult to diagnose due to the generalized nature of symptoms: pelvic pain, dysmenorrhea, dyspareunia, and dysuria/dyschezia [12]. Symptoms associated with bowel endometriosis are abdominal pain relieved with defection, change in frequency or appearance of stool, and abnormal rectal bleeding, but most of these symptoms are seen only in cases of mucosal involvement [13]. Additionally, it is difficult to diagnose bowel endometriosis even with colonoscopy as most cases do not infiltrate beyond the serosa and very few infiltrate the mucosa [14]. With a wide range of presentations and the often asymptomatic disease course, until it significantly progressed, deep infiltrating endometriosis is a complicated disease to diagnose and treat.

The treatment of endometriosis has primarily focused on alleviating symptoms and restoring fertility in women of reproductive age [15–17], but to this point, no curative therapy exists. To date, research has primarily focused on the surgical treatment of deep endometriosis with fewer resources being devoted to understanding the medical management of the disease. Specifically, research in postmenopausal endometriosis has purported to indicate the necessity of resection due to the risk of malignancy [18, 19]. However, recurrence of the disease is possible even with surgical intervention, and there is a risk of significant complications as a result of surgical resection especially in bowel endometriosis [20]. There has been a rise in invasive bowel resection for treatment of colorectal endometriosis in recent years, and some authors have begun to question the efficacy of such a practice in favor of less invasive interventions such as ablation or medical management [21–23]. Complete excision of endometriosis of the bowel, more than ablation, has been shown to reduce some symptoms such as dyspareunia, but overall symptoms are decreased nearly identically with ablation or excision [24]. The difficulty of completely eliminating endometriosis of the bowel and permanently reducing symptoms is the preferential association of endometriosis tissue with the enteric nervous system, which also accounts for the set of symptoms seen in deep infiltrating endometriosis of the bowel [13, 25, 26]. Additionally, macronodules of endometriosis may be readily visible during surgery, but micronodules are identified in histology making complete excision of endometriosis unlikely [27]. As discussed here, many complicating factors are associated with surgical intervention in deep infiltrating endometriosis in a postmenopausal population. A more patient-oriented approach evaluates specific patient factors as in this case, demonstrating a less invasive method, that is, ablation followed by CE/BZA therapy in this case.

Medical management of endometriosis and especially postmenopausal endometriosis is evolving. The currently postulated mechanisms of premenopausal endometriosis include retrograde menstruation, coelomic metaplasia, immune deficiencies, and Mullerian remnants, but these do not adequately account for all cases in women of reproductive age [17]. Postmenopausal endometriosis cannot be fully explained by the postulated mechanisms, but high levels of ectopic estrogen production from nonovarian tissue can activate endometrial tissue [28]. Aromatase has been shown to have a role in the pathogenesis of endometriosis and has long been a proposed target for treatment [29]. Few cases of the treatment of postmenopausal endometriosis with aromatase inhibitors (AI) have been reported; however they suggest that significant symptom reduction is possible with AIs [18]. One case even notes the positive effects of AIs on abdominal endometriosis and suggests a potential role for AIs in the treatment of postmenopausal deep infiltrating endometriosis [30]. Although there are articles demonstrating the usefulness of AIs in postmenopausal endometriosis, empiric research is lacking.

CE/BZA was approved in 2013 for treatment of the vasomotor symptoms associated with menopause as well as the treatment of postmenopausal osteoporosis by a non-hormone replacement therapy/menopausal hormone therapy mechanism [31]. CE/BZA is a combination of conjugated estrogen and bazedoxifene, a selective estrogen receptor modulator (SERM) that induces degradation of estrogen receptors in breast and endometrial tissue [32]. Original clinical trials validated the efficacy of CE/BZA in reduction of menopausal vasomotor symptoms and protection against osteoporosis, while demonstrating the protective effects of bazedoxifene on breast and endometrial tissue in the presence of estrogen [33]. Research has also shown that CE/BZA can cause regression of endometriosis in a murine model [34, 35]. It was by this mechanism hypothesized that CE/BZA would be an ideal option for medical management in this postmenopausal patient thereby inducing regression of endometrial tissue while providing the protective bone effects of estrogen and preventing vasomotor symptoms of menopause.

In conclusion, this case highlights an unusual presentation of iron deficiency anemia due to a rare colonic location of deep infiltrating endometriosis in a postmenopausal woman successfully treated medically with a novel and less invasive approach (CE/BZA) that provides mechanisms for both symptom control and disease regression.

Consent

Informed consent was obtained from the patient discussed in this case report.

Disclosure

Gary A. Abrams is the article guarantor. The source is Greenville Memorial Hospital, Greenville, SC.

Conflicts of Interest

The authors declare that there are no conflicts of interest regarding the publication of this paper.

Acknowledgments

Funding for this submission is provided by the Department of Medicine at Greenville Memorial Hospital.

Symptomatic endometriosis developing several years after menopause in the absence of increased circulating estrogen concentrations: a systematic review and seven case reports | Gynecological Surgery

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  • Diagnosed With Endometriosis After Menopause – Dorran’s Story

    Dorran was diagnosed with endometriosis after menopause. Her history of gynecological surgeries includes treatment for multiple GYN conditions over the past 17 years, but she continued to have pain until she met Natalya Danilyants, MD, in 2015.

    “In 1999, I had an open surgery, c-section style for fibroids,” Dorran said. “Then seven years later, in March 2006, I had a hysteroscopy procedure for fibroids and a cyst. I went into the hospital for a ruptured ovarian cyst. I was in so much pain I couldn’t move.”

    Even after that surgery, Dorran was still in constant pain.

    “I followed up with my gynecologist, but he couldn’t find anything wrong,” Dorran said. “He diagnosed me with fibromyalgia, but that had nothing to do with the pain I was experiencing. In 2005, I became pre-menopausal. When I had the surgery the following year, I wasn’t having a menstrual cycle at all, so I thought it was weird that I was having cramps, and that they were sporadic.”

    Still experiencing pain, nine years later, Dorran had another procedure.

    “In 2014 I had another hysteroscopy and they said I had adhesions, polyps and my cervix was closed,” she said. “I didn’t understand why I was always in pain. Sometimes people are not persistent enough. I was sick for a while. I went through ovarian cancer testing. I was so stressed, wondering if the pain was a figment of my imagination.”

    Everything changed when Dorran met Dr. Danilyants.

    “I explained what I was going through to my internist, and he told me that his wife recently had a procedure with Dr. Danilyants,” Dorran said. “Given what I was experiencing, he recommended I see her.”

    Are you experiencing unexplained pelvic pain? It could be an undiagnosed GYN condition. Talk to a patient advocate about seeing a specialist.

    Getting Diagnosed with Endometriosis

    “Endometriosis is undetectable unless seen through laparoscopy, and it turns out, that’s what I had,” Dorran said.

    Dorran most likely had endometriosis for years before menopause, as it is unlikely to develop after the onset of menopause. Endometriosis is fueled by estrogen. After menopause, estrogen production diminishes. However, women with advanced stage endometriosis can often have long-term pelvic pain associated with the damage that endometriosis caused before menopause.

    On average, women with endometriosis often wait a decade for a proper diagnosis. Even though many women start to experience symptoms in their teens, many do not see a gynecologist for the first time until their 20s, and it is rare for a woman to seek out a specialist at that age unless she is in severe pain. But that pain is subjective and is often dismissed even by medical professionals as a normal part of menstruation.

    Delaying diagnosis and treatment gives endometriosis time to do a lot of damage. Pelvic adhesions can form due to the inflammation from the endometrial implants, and fertility can be compromised. If diagnosed and treated early, there is a higher chance that treatment will be more effective and there will be less damage to the reproductive system.

    Choosing A Minimally Invasive Hysterectomy

    For most cases of endometriosis, excision surgery is the most effective treatment. But for some cases of endometriosis in severe advanced stages, a hysterectomy that removes the ovaries may also be necessary to relieve symptoms. While a hysterectomy does not cure endometriosis, removing organs that have been damaged due to pelvic adhesions and inflammation can alleviate pain.

    “I’m 61. I don’t need these organs. I had a complete laparoscopic hysterectomy,” Dorran said. “After surgery with Dr. Danilyants I could tell this time was different. I don’t like taking medicine. I had painkillers when I left. I got home from the surgery, I had one when I got home and that was it. I had surgery on a Thursday, rested on Friday and on Saturday I was up and doing normal stuff. Now I feel like I could run a mile. I don’t feel like I just had surgery.”

    “When I was getting ready to come back to work from surgery, I had to get my hair done. The hairdresser was amazed that I could lean back. You can see the difference after a minimally invasive hysterectomy. When I had my open surgery and had to go back to work, it took forever not to feel pain. Even the difference of walking outside, you put your foot on the cement versus walking around the house in your slippers and it’s jarring. It was very different this time.”

    Live your life — pain-free. Talk to a patient advocate to get started on your health journey today.

    Life After a Laparoscopic Hysterectomy at CIGC

    “I feel so light now,” Dorran said. “Before I felt tired, slow and mentally drained. I was going through the motions. I’m a senior manager. I don’t have time to stop. I’m working 12-hour days and when I come home, I have elder care. It was just a mental drain. All of my activities: work, elder care, none of that feels as heavy anymore. Nothing is slowing me down now. Dr. Danilyants has given me my life back. I registered to take a class online. Now it doesn’t seem like I’m juggling a lot of things. I feel jubilant!”

    Just before the surgery, Dorran traveled to Manila, Philippines, unsure of how she would feel after her surgery.

    “I didn’t know if I would be able to be as active afterward,” she said. “I had enough ibuprofen with me. That was the longest trip I’ve taken in the last two years. But now I can do anything! I started taking classes in CAD design. I’m an IT professional, but I like fashion, I like design, so I thought after I retire, I would like to freelance as a CAD designer.”

    BOOK A CONSULTATION

    CIGC specialists are available at two locations in the D.C. metro area. Virginia patients can visit the Reston, VA. Our Maryland office is located in Rockville, MD. Saturday appointments are available in both Rockville and Reston. Or visit CIGC in our Montclair, NJ or Manhattan, NY locations

    CIGC is dedicated to providing information and materials for women to help navigate the complicated health care system. The CIGC founders, minimally invasive GYN surgical specialists Dr. Paul MacKoul, MD, and Dr. Natalya Danilyants, MD, developed their advanced GYN surgical techniques using only two small incisions with patients’ well-being in mind.

    Their personalized approach to care helps patients understand their condition and the recommended treatment so they can have confidence from the very start. Our surgeons have performed over 25,000 GYN procedures and are constantly finding better ways to improve outcomes for patients.

    Book a consultation today with Paul MacKoul, MD, or Natalya Danilyants, MD.

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    90,000 Endometriosis: Diagnosis, Treatment, Specialist

    Definition: what is endometriosis?

    Endometriosis (proliferation of muscle tissue in the uterus) is the second most common gynecological disease after fibroids.

    The term “endometriosis” comes from the Greek language and means a disease (-osis) of the inner layer (-endon) of the uterus (-metra), also known as pathological changes in the endometrium. In particular, we are talking about the proliferation of the mucous membrane outside the uterine cavity.In this case, damage to the muscular membrane of the body of the uterus (genital internal endometriosis), the lower abdomen, ovaries, pancreas, bladder, rectum and even the lungs can occur. This disease occurs in sexually mature women. The main age of patients diagnosed with endometriosis varies from 20 to 40 years. 10% of women 15-50 years old suffer from this disease, while the number of cases is constantly growing.

    Reasons: why does endometriosis occur?

    Until now, the exact causes of endometriosis, unfortunately, have not been identified.However, there are various assumptions among which the theory of transplantation seems to be the most popular. According to this opinion, during each period (menstruation), part of the lining of the uterus (endometrium) moves not only outward (vagina), but through the fallopian tubes and inward, into the abdominal cavity. There, the fabric can become fixed and cause problems over time.

    Especially women with strong and frequent menstruation suffer from this. In addition, the early appearance of the first menstruation and later – the last (menopause), contributes to the development of endometriosis.There is also a connection with a hereditary factor.

    What are the symptoms of endometriosis?

    The entire lining of the uterus, whether in the uterus or elsewhere in the body, depends on the natural cycle of hormones. This means that it is growing. If there is no pregnancy, the top layer is rejected and the menstrual period begins.

    The mucous membranes in the fallopian tube or abdominal cavity also carry out this cycle. This can lead, among other things, to severe cramping abdominal pain, as well as persistent back pain, abdominal pain and menstrual irregularities.As a rule, such pains are difficult to distinguish from regular menstruation.

    Depending on the location of endometriosis, pain may also appear during intercourse, bowel movements and urination. Often the symptoms are so nonspecific (in 50% of patients the symptoms are absent or very mild) that the correct diagnosis is made too late.

    The most common (about 50% of cases) endometriosis affects the ovaries. Endometriosis due to replacement of normal ovarian tissue can cause infertility.About 15-25% of cases of infertility in women are caused by this particular pathology.

    Diagnosis: How is Endometriosis Detected?

    An accurate medical history is of great importance. In addition, the presence of cases of the disease in the family is taken into account, as well as the nature and frequency of complaints.

    This is followed by a gynecological examination. Palpation of the vagina and uterus is usually ineffective here. Examination with a gynecological speculum can reveal a large lesion in the vagina or cervix.But ultrasound alone is usually not enough, as it does not fully visualize the ovaries or abdomen.

    Only laparoscopy will help here. In this study, through special holes, tissue is taken, as well as part of the focus, for subsequent research. Then the diagnosis is confirmed by laboratory.

    Treatment: how is endometriosis treated?

    Treatment of endometriosis consists in the surgical removal of the entire lesion. It is removed either by excision (extirpation) or by destruction by heat (electrocoagulation, laser).The operation, if possible, is performed laparoscopically. At the same time, any adhesions on the ovaries are also removed, and then the patency of the fallopian tubes (if you wish to have children) is checked using dyes.

    If surgery cannot be performed laparoscopically due to the strong growth of tissue in the abdominal cavity, a strip operation is performed.

    Sometimes the uterus is removed (for genital internal endometriosis). At the same time, however, the thought of childbearing should be abandoned.

    It is also possible, and sometimes necessary, simultaneous therapy with hormonal drugs as protection against relapse. The attending gynecologist will tell you which drugs are effective and which have side effects.

    What is the prognosis and course of the disease in endometriosis?

    Endometriosis is a chronic disease with a very high relapse rate (high likelihood of relapse).

    During pregnancy and artificial pregnancy (pills), the symptoms are significantly reduced.After stopping the medication, however, endometriosis may recur.

    The chances of endometriosis cells becoming cancerous are very low. In this case, it is usually detected and treated early.

    Important: Estrogen monotherapy during menopause can worsen endometriosis and increase the likelihood of malignancy.

    At the end of the fertile period (after menopause), the symptoms disappear on their own and over time, as does the focus of endometriosis.

    Where can I find a specialist in the treatment of endometriosis?

    Endometriosis specialists are doctors with a specialization in gynecology (obstetrics and gynecology). Since 2005, clinics can be certified as centers for the treatment of endometriosis. The aim is to enable patients to receive optimal medical treatment in accordance with the latest scientific standards through interdisciplinary collaboration and research.Here you will find specialists and medical centers in the field of endometriosis treatment in the following cities:


    List of all centers for the treatment of enometriosis in Germany



    can be found on the community website Endometriose Vereiningung Deutschland e.V.


    Sources:

    Stauber, Manfred; Weierstal, Thomas (2007): Obstetrics and Gynecology. Third updated edition. Stuttgart: Georg Thieme (Duale Reihe).

    Keck, Christoph; Denschlag, Dominik; Tempfer, Clemens (2004): Exams in Obstetrics and Gynecology. 1000 questions with comments; 6 tables. Stuttgart: Thieme.

    Endometriosis with menopause

    27.08.2020

    Climax often causes great changes in the female body. They are often difficult to tolerate. In the period menopause can develop diseases that have never occurred before. For example, endometriosis.

    What is endometriosis?

    Endometrium is the tissue that lines the inner surface of the uterus .Endometriosis is the proliferation of endometrial cells that extend beyond the uterus . ovaries , cervix can be affected. Cells can also grow in the abdominal organs and even in distant cavities.

    Some women assume that menopause and endometriosis are not compatible phenomena. However, every year more and more doctors diagnose the disease during this period.

    It is important to remember that endometriosis at climax shows symptoms and requires treatment of a slightly different nature than at fertile age.

    Symptoms of endometriosis with menopause

    Endometriosis can manifest itself in different ways. It depends on the lesion. Often women regard painful and unpleasant sensations as the beginning of menopause .

    The following are considered the most common symptoms:
    • painful sensations;
    • selection. They can be in the form of the usual profuse, minor with blood , sometimes bleeding occurs;
    • dizziness ;
    • fatigue, general weakness.

    In addition to these signs, chills, nausea and vomiting, temperature fluctuations may be observed, an increased level of leukocytes is found in blood .

    When a woman is diagnosed with endometriosis of the uterus at climax , the symptoms and treatment of this ailment can be varied. The main symptom is severe pain in the lower abdomen , pelvis.

    Treatment of endometriosis during menopause

    Endometriosis at menopause requires treatment.Specialists carry out treatment in the following ways: conservative, operative and combined.

    The method depends on the lesion site, clinical manifestations and the degree of cell proliferation. The choice of a method for treating endometriosis at climax is more difficult, because the hormonal background is disturbed.

    Conservative treatment is used at the initial stage. It involves the use of hormonal drugs. It is necessary to either neutralize the hormonal imbalance or reduce the production of estrogen.

    Surgical treatment – removal education by surgical way. By the method of laparoscopy, areas of the endometrium are removed and cauterized. In severe cases with severe damage , doctors can remove uterus and / or ovaries . It is used only in the case when the treatment with medications did not bring the desired result.

    The combined type is considered the most efficient. It involves the use of medications and laparoscopy.

    In addition to the above methods, women resort to traditional methods of treatment (honey, herbs, propolis, etc.). However, this can only aggravate the condition. It is best to seek help from a specialist.

    Danger of degeneration into cancer

    There is an opinion that endometriosis at climax is cancer . Fortunately, this is a myth. However, there is a danger during the menopause of the formation of cancer cells. Physicians can detect neoplasms of both benign and malignant nature.

    Symptoms of endometriosis after menopause

    After climax endometriosis has different symptoms. Basically, it is manifested by the following symptoms:

    1. headache. In the first 15 days of the month, women suffer from severe headaches, and for the next 15 days they notice a slight malaise;
    2. selection. Bloody discharge is replaced by severe bleeding. During this time there is nausea , vomiting, fever;
    3. nervousness. The nervous system is in a state of excitability. Patients complain of insomnia , increased irritability.

    Treatment of postmenopausal endometriosis

    The treatment methods are the same as for endometriosis during menopause .

    The hormonal course of medication lasts for 6-9 months.

    Endometriosis after menopause entails serious consequences, experimentation and self-medication can harm the body and aggravate the condition.Only with the permission of the doctor can they be combined with medication.

    Conclusions

    The proliferation of endometrial cells during the climax is a frequent occurrence. Symptoms, especially early on, may be mild. Based on this, it is important for women to monitor all changes in the body and respond in a timely manner, seeking help from a doctor . Diagnosis of the disease at a late stage can result in removal of of the damaged organ.

    Navigation through records

    38 Frequently asked questions about endometriosis. Women’s Barcelona

    other classification of endometriosis . The most commonly used is the American Society for Reproductive Medicine (ASRM), which classifies the disease into 4 stages: 1 (minimal), 2 (mild), 3 (moderate), and 4 (severe). Although this classification is the most widely used, it has several disadvantages. Thus, patients with the same stage may have different presentation forms.Also not included are some serious forms of the disease (such as those affecting the intestines or the bladder). and this is the postoperative classification. Therefore, it is preferable to classify patients on the basis of the endometriosis type they are present, which gives more information about the prognosis and the prescribed treatment.

    Therefore, it is preferable to classify endometriosis according to the type of disease presented by the patient: superficial peritoneal endometriosis , cystic ovarian endometriosis (endometrioma or “chocolate cyst”, known as such by the appearance of its contents) and deep endometriosis (also called infiltrative endometriosis).These different types usually occur at the same time (that is, a patient may have more than one type of endometriosis in the pelvis).

    Superficial peritoneal endometriosis

    Injuries affect peritoneum , which is a very thin tissue that lines the inner wall of the abdominal cavity as a lining. The lesions are flat and dark and do not penetrate the underlying tissue.

    Cystic ovarian endometriosis (endometrioma)

    Un endometrioma is an ovarian cyst the inner wall of which is lined with ectopic endometrial tissue.The cyst is filled with fluid made of old blood. Due to the color and appearance of this fluid, these cysts are called “ chocolate cysts .” Many women with endometriosis also have deep endometriosis , especially if they have severe pain.

    Deep endometriosis

    Finally, the most serious type of disease is deep endometriosis . So we determine the foci of endometriosis 5 mm or more below the surface of the peritoneum, affecting tissues and organs located there (intestines, ureter, bladder, nerves, etc.)Etc.).

    90,000 Endometriosis: See and Treat

    At the end of May, the 13th World Congress dedicated to this disease was held in Vancouver (Canada). One of the participants in this large-scale session, Alexander Aleksandrovich Makolkin, gynecologist-reproductologist at the Scandinavia and AVA-PETER clinics, spoke about the difficulties in achieving the goals of endometriosis treatment.

    – Alexander Alexandrovich, endometriosis is called the disease of theories – why?

    – Despite all the efforts of scientists and doctors, endometriosis remains one of the most mysterious diseases in gynecology.The essence of this disease is as follows: the endometrium (the mucous membrane lining the uterine cavity) appears outside the uterine cavity. The cells are fixed in new places and begin to grow there. Pathological foci can appear not only in the genitals, but also on the bladder, intestines, kidneys, and even on the lungs and lacrimal glands. However, we do not yet know the cause of this process, nor the exact mechanism of its development – all explanations exist only in the form of assumptions. One thing is clear: endometriosis significantly reduces a woman’s quality of life.And those girls who experience severe pain during menstruation or during intimacy know what I’m talking about.

    – It turns out that it is not so difficult to identify endometriosis: severe pain during menstruation, excessive discharge, pain during intercourse – these are quite pronounced symptoms …

    – Yes, but all these are signs of severe forms of endometriosis. In small forms, discomfort may practically not be felt and not cause anxiety in the woman. According to the data announced at the congress in Vancouver, the time from the appearance of the initial complaints to the beginning of the diagnosis is, on average, about 10 years! Quite often, the only clinical manifestation of this disease is infertility, and endometriosis is detected when a woman comes to the doctor to find out why she does not get pregnant.

    – How exactly does endometriosis provoke problems with conception?

    – Good question, but we are still looking for the exact answer to it. However, the fact that endometriosis worsens the prognosis for the onset and course of pregnancy is a proven fact. In 2015, on the basis of the clinic, we conducted a study on the effect of endometriosis on the outcomes of ART cycles. And, unfortunately, the pregnancy rate in our patients with endometriosis turned out to be lower than in patients who do not suffer from this disease.So you need to treat it in any case, and especially if the conception of a child is in the immediate plans. This is confirmed by the rule established by the European guidelines for the treatment of endometriosis: ‘see and treat’.

    – What tests can be used to identify the disease?

    – It is possible to suspect the presence of endometriosis already at the stage of collecting anamnesis, indirect confirmation is provided by ultrasound (especially 3D) and MRI with contrast, as well as a blood test for the CA-125 antigen content, and a number of other studies.However, the final diagnosis is possible only with direct visual identification of foci during the operation. The most accurate diagnostic method is laparoscopy followed by histological examination of the tissue. Only then do we have a verified (confirmed) diagnosis. And, by the way, a diagnostic operation often turns into a therapeutic one – in many cases we can not only identify the focus of endometriosis, but also immediately remove it.

    – Laparoscopy, although sparing, is still an operation – how justified is the surgical approach in the treatment of endometriosis?

    – An operation is definitely indispensable if a woman, for example, has an endometrioid ovarian cyst or there is an invasion of endometrioid foci into the intestines, into the bladder.In most cases, these processes are benign, but a combination with oncological diseases is also possible – in particular, ovarian cancer associated with endometriosis. This is already a great risk to life, and, accordingly, any such formation should be excised in full. Of course, the question of the operation is decided strictly individually: first of all, the doctor should pay attention to the stage, form of the disease, the patient’s age, her plans to replenish the family. But in any case, it is surgical intervention that can guarantee the maximum suppression of the activity of endometriosis.But this result is also relative. Relative – because endometriosis tends to recur. And thanks to the operation, we get a significant delay, which, for example, can be used to give birth to a child. After surgical treatment of endometriosis, you can go in two ways: either immediately plan a pregnancy, or undergo hormonal therapy in order to consolidate the result and delay the possible relapse of the disease as much as possible.

    – Many women are afraid of hormone therapy in the treatment of endometriosis.They say these drugs cause menopause – is it true?

    – Yes, quite aggressive drugs are sometimes used in the treatment of endometriosis, which lead to artificial reversible menopause and thereby stop the development of the disease. Unfortunately, they also cause all the symptoms typical of menopause in a woman: hot flashes, nervousness, irritability, decreased bone density with prolonged use. However, there is an alternative to them – drugs that also exclude menstruation, but do not suppress ovarian function.The latter continue to work in the same mode, and the woman even feels her cycle, although there seems to be no menstruation. As a result, the activity of endometriosis decreases and there are no symptoms of menopause. You can stay on such treatment for a long time and without any consequences.
    – And after such a comprehensive treatment of endometriosis, including surgery and hormonal therapy, will a woman be able to become pregnant?
    – Of course, for this is what we are doing! Having eliminated the manifestations of endometriosis, if necessary, we begin therapy that promotes the early onset of a natural pregnancy, or we plan an IVF cycle.And even in preparation for conception, you can use drugs that in parallel continue to suppress endometriosis. That is, all our activities are logical and well thought out. Gynecologists, obstetricians, reproductive doctors in ART departments – we all work harmoniously and together so that as a result a woman would feel good and, if desired, could become pregnant and give birth to a healthy child.

    Date of publication: 06/28/17

    (PDF) Management of menopausal women with a history of endometriosis

    GYNECOLOGY 2019 | VOLUME 21 | # 6 / GYNECOLOGY 2019 | Vol.21 | No. 6

    42

    Elena I. Ermakova, et al. / Gynecology. 2019; 21 (6): 41–44.

    A woman should be informed that the drugs

    for MHT do not have a contraceptive effect.

    • Monophasic combination therapy in continuous mode

    is indicated for postmenopausal women with an intact

    uterus.

    When considering the possibility of using MHT by the patient,

    should adhere to the so-called

    my temporary hypothesis: start hormone therapy at the age of

    growing younger than 60 years or with the duration of postmenopause

    less than 10 years [2, 3] …

    It is recommended to titrate the dose of drugs to the lowest

    optimal and most effective [2, 3, 6]. In the Russian Federation

    Oral pre-

    paras of MHT are registered with the inclusion of standard (2 mg), low

    (1 mg) and ultra-low (0.5 mg) doses of estrogen. Low-dose

    and ultra-low-dose oral estro-

    genes are equally effective in treating vasomotor

    symptoms and have a more favorable side-effect profile of

    compared to standard doses of

    monos.Low-dose MHT (1 mg estradiol) can be prescribed

    in early postmenopause (one year after the menopause

    ), and then it is possible to switch to an ultra-

    early low-dose regimen (0.5 mg estradiol) with storage

    indications for treatment [6].

    The latest recommendations of the International Menopause Society

    (IMS) [2] indicate that the safety data

    low- and ultra-low-dose estrogen-

    progestogen drugs are encouraging, since with their

    use there are fewer cases of unfavorable –

    pleasant events, but wait for the results of

    larger prospective studies.

    When prescribing MHT drugs, the doctor’s task is to take an individual regimen for each patient and

    route of administration of drugs, taking into account the severity of symptoms, personal and family history, results of corresponding studies, preferences and expectations

    women [6].

    Particular attention should be paid to patients with a history of endometriosis in the selection of MHT and follow-up

    in order to minimize and early detection of risks

    and side effects of hormone therapy.

    MHT and endometriosis

    Endometriosis is an estrogen-dependent chronic disease

    in which the endometrial glands and stroma are exposed outside the uterine cavity. According to the latest data,

    more than 80 million women in the world suffer from this disease

    [7]. Since endometriosis is an estrogen dependent disease

    , it is generally considered a pro

    blem of reproductive age, resulting in a syndrome

    of chronic pelvic pain and infertility.In the majority of

    cases, the symptoms and manifestations of this pathology disappear with the onset of menopause.

    The management of women with a history of endometriosis requires a special approach

    . The question of prescribing MHT to such patients causes a lot of controversy, since hormone therapy

    can activate residual foci of endometriosis and

    cause a relapse of the disease or contribute to the emergence of new lesions [8]. In addition, it is necessary to take into account the

    risk of malignancy of endometrioid heterotopias without additional

    additional influences or with the participation of MHT.

    On the other hand, women with a history of endometriosis

    may be at particular risk due to a long-term temporary state of estrogen deficiency following

    as a result of repeated courses of gonadotropin-rili analogs

    zing hormone, depot of progestogens or surgical interventions –

    steps. Reoperations on the ovaries result in

    damage and loss of functional tissue. Sometimes, with

    severe forms of the disease in premenopausal women, it is necessary

    to perform hysterectomy and bilateral ovariectomy

    to stop symptoms and avoid further

    surgical interventions.The fight against endometriosis by

    by similar aggressive methods raises a wave of new

    problems associated with menopause. In this regard, a number of questions arise: is it reasonable to appoint MGT? What kind of rice can it lead to? What type of MHT should be offered

    and when to start treatment? What alternatives to MGT should

    be offered? How should

    patient data be monitored?

    According to the IMS recommendations [2], premature (up to

    40 years) and early (40–45 years) menopause are associated with a high incidence of cardiovascular diseases, the development of

    osteoporosis, cognitive disorders, Parkin’s disease

    90,004 sone and a higher mortality rate.Therefore, young

    smoke for women (up to 45 years old) with climacteric disorders

    should be recommended MHT, at least

    until the average age of natural menopause is

    [9]. Hormone therapy should also be considered for

    women with a history of endometriosis during natural menopause

    , with severe climacteric disorders

    [2, 9].

    The most important problems of MHT use in this

    category of patients are the risk of recurrent endometriosis

    and the associated potential need for surgical intervention.To date,

    the literature describes many cases of endometriosis in

    menopause, especially ovarian and extragenital lo-

    calization (intestines, bladder, ureter, lung,

    liver and skin) [10]. The prevalence of this pathology

    among women of peri- and postmenopausal age, according to the data of a few retrospective studies

    , is 2–5% [7]. So, Henriksens studied

    1 thous.patients over 20 years of age with endometriosis, of which

    , 37 (3.7%) were menopausal [11]. In 1980

    R. Punnonen et al. showed that in the study group

    women with ovarian endometriosis, the frequency of postmenopausal endometriosis was on average 2.2%, and the average

    duration of menopause until the moment of di-

    agnosis was 7.3 years [7]. In 1984, the same research group

    analyzed the case histories of 801 women of different

    age groups who had surgical interventions –

    in the anamnesis for various gynecological reasons in the

    period from 1969 to 1976.It was shown that 19% of them had en-

    homemetriosis, and cases of this pathology in postmenopausal women were observed in 2.5% of women [12]. In a recent retrospective

    epidemiological study, D. Haas et al.

    analyzed 42 079 cases of surgically confirmed

    endometriosis in clinics in Germany. In 1074

    (2.55%) women from this number, postmenopausal

    endometriosis (age from 55 to 95 years) was revealed [13].

    The role of MHT in the development of postmenopausal endometrium

    Riosis was studied in randomized clinical trials

    followings.Fedele et al. for 12 months, 21 women with residual manifestations of endometrium

    riosis after bilateral oophorectomy with hysterectomy or without hysterectomy were examined

    . Patients with a preserved uterus (n = 10)

    received cyclic MHT: transdermal estradiol at

    at a dosage of 50 mg 2 times a week and medroxyprogesterone

    acetate 10 mg per day 12 days a month. The rest of the patients

    were constantly receiving tibolone (2.5 mg per day).After 12 months of

    therapy, 4 (40%) patients from group 1 and 1 (9%) in the

    tibolone group noted recurrence of pelvic pain [7, 14].

    In a large randomized study R. Matorras

    et al. 172 women took part who underwent double-

    ronny adnexectomy with or without hysterectomy according to

    water of endometriosis. 4 weeks after surgery, 115 of them

    received hormone replacement therapy (HRT):

    transdermal estradiol 50 μg 2 times a week plus

    micronized oral progesterone 200 mg on

    day 14 days a month.The control group (n = 57) did not receive

    hours of HRT and placebo. The observation period was 45 months. It was shown that

    showed that in the HRT group there were 4 cases of recurrence of endo-

    metriosis (0.91% per year), in the group without HRT – 0. In addition, investigators drew attention to the fact that bilateral ad-

    nexectomy without hysterectomy, as well as peritoneal

    endometrioid infiltrates more than 3 cm are factors of risk of recurrence of endometriosis against the background of

    taking HRT [15].

    Endometriosis: causes, symptoms, diagnosis and treatment

    In their daily hustle and bustle, women do not always pay attention to any manifestations related to their health. Painful periods? Fate – so it was with my mother. Does your lower back pull? I ran all day in high-heeled shoes.

    And everything would be fine if some of these symptoms did not hide a mysterious disease. His name is endometriosis.

    Gynecologists Olga Evgenievna Malafeeva and Alexandra Alekseevna Dobrenko tell about what kind of disease it is.

    – Olga Evgenievna, what is endometriosis and how often does this disease occur in women?

    – This is a hormone-dependent disease. It is characterized by an atypical arrangement of cells in the inner (mucous) layer of the uterus – the endometrium. In other words, not where it should be normal, but in other places.

    Statistical data vary, but it is known that endometriosis ranks third in the structure of gynecological diseases. Usually women of reproductive age suffer, most often – 20-40 years.Now there is a tendency to expand the age range: the newly diagnosed endometriosis has been described in both adolescents and women entering menopause.

    – You said that with this disease, endometrial cells appear in other parts of the body. The question arises: is endometriosis some kind of cancer or is it not?

    – No, in no case should an equal sign be put between them.

    – Can endometriosis develop into cancer?

    – Only with the so-called atypical form of endometriosis (no more than 1% of cases of endometriosis).

    – What organs does endometriosis affect?

    – This can be, for example, the vagina, cervix, myometrium, fallopian tubes, ovaries, peritoneum, intestines, bladder. There is also postoperative scar endometriosis.

    – Why does endometriosis occur?

    – To date, the causes of the occurrence are not fully known. There are various theories explaining the development of this pathology. For example, retrograde: it is assumed that endometriosis occurs due to the reverse flow of menstrual blood, with its throwing through the fallopian tubes into the abdominal cavity.

    The reasons for the occurrence are not fully understood.
    Probably with the development of endometriosis
    More than one factor plays a role

    There is a theory of genetic predisposition to the disease, “hormonal” theory (against the background of an incorrect ratio of female sex hormones), lymphatic, as well as autoimmune theory. It is possible that more than one factor plays a role in the development of endometriosis.

    – Alexandra Alekseevna, do you think a healthy lifestyle, a balanced diet – these factors will help reduce the risk of endometriosis?

    – Undoubtedly.And this applies not only to endometriosis: the absence of bad habits and proper nutrition will help to avoid many diseases.

    It is quite possible to eat properly. It is enough to approach this issue thoughtfully. Quote from the material “Rules of healthy eating. What do you need to eat to be healthy? ”

    – Olga Evgenievna, tell us, what are the symptoms of endometriosis?

    – The most common and significant symptom of endometriosis in women is chronic pelvic pain.Infertility is also noted; menstrual irregularities; severe pain during and outside the period, located in the lower abdomen, in the lower back and thighs. Pain during intercourse may occur. When the process spreads to neighboring organs, there may be pain during urination and the act of defecation.

    Chronic stress – poor prognostic
    factor for the development of many diseases

    – Who is at risk for endometriosis?

    – These are women of reproductive age with inflammatory processes of the genital organs; after an ectopic pregnancy, cesarean section, curettage of the uterine cavity and other surgical interventions on the uterus.Stress, prolonged and intensive work schedule, “hard” diets, and smoking increase the likelihood of developing endometriosis.

    – Alexandra Alekseevna, your opinion: can constant stress, without which, alas, it is impossible to do in modern life, somehow provoke the appearance of the disease?

    – Chronic stress has always been a poor prognostic factor for the development of many diseases, including endometriosis. It is dangerous in that it has a cumulative effect and acts on the body according to the principle of a delayed-action mine: we never know when and in what “area” of our body it will “explode”.The accumulated stress can result, for example, in a neuralgic ailment, or cancer can develop.

    – Olga Evgenievna, how is endometriosis diagnosed?

    – Examination for endometriosis begins with a detailed collection of complaints and anamnesis, general and gynecological examination. Colpo- and cervicoscopy is performed, according to indications – hysteroscopy. If there is a suspicion of involvement of the bladder in the process, cystoscopy is performed, and the colon – a colonoscopy.

    Ultrasound (mainly transvaginal) and MRI of the pelvic organs are used. Determination of markers CA 125, CEA, CA 19-9 in the blood is of diagnostic value. Laparoscopy is also used.

    About the correct preparation for the gynecological (small pelvis in women) ultrasound, read here

    – On various forums you can find information that the most informative diagnostic method for endometriosis of the uterus is laparoscopy. Is it really so?

    – Depends on the form of endometriosis.If it is necessary to diagnose the process coming from the inside of the uterus – internal endometriosis (adenomyosis), then the use of hysteroscopy is more informative. But if we are talking about the external form of endometriosis – on the peritoneum, ovaries, adjacent organs – yes, laparoscopy is considered the “gold standard” of diagnosis.

    – Is endometriosis a lifelong sentence or is it being successfully treated?

    – This, of course, is not a sentence. However, endometriosis requires long-term, persistent treatment.Usually the process ends with the cessation of reproductive function, i.e. in the climacteric period, it does not progress.

    In the climacteric period
    endometriosis does not progress

    – Is conservative treatment of endometriosis possible?

    – Yes, conservative treatment is carried out for early, non-cystic forms of endometriosis (cysts are recommended to be removed). From medications, various hormonal drugs, non-steroidal anti-inflammatory drugs (NSAIDs) are used.Physiotherapy is also used. Surgical operations are performed according to indications. Treatment is usually complex.

    – Alexandra Alekseevna, on the Internet you can find many ways to treat endometriosis using folk methods: this is the use of medicinal plants, and various kinds of compresses, tinctures, ointments. What is the attitude of mainstream medicine to this? Is it really that some “grandmother’s” recipes can really help in the treatment, or should we treat them with reasonable skepticism?

    – I will say right away: if we talk about the treatment of endometriosis, the attitude of official medicine to the “grandmother’s” methods is definitely negative.For this, there are a variety of medications used, as a rule, in a complex manner, their effectiveness has been tested by practice. However, we also do not forget about traditional medicine, since the basis of many medicines is made up of extracts of medicinal plants. Yes, of course, you need to follow the doctor’s recommendations and use the drugs prescribed by him, but it will not be worse if the menu includes, say, cruciferous plants – the same parsley, carrots. Because it is known: phytoestrogens – natural non-steroidal plant compounds – are very beneficial for women’s health.

    – Olga Evgenievna, what is the danger of endometriosis for a woman if it is not treated?

    – The consequences of untreated endometriosis can be constant, exhausting pain. The development of infertility is possible. In the presence of a process in adjacent organs, a violation of their functions.

    – What is endometriosis prevention? What measures can a woman take in order to protect herself from this disease?

    – Abortion should be avoided.For any irregularities in the menstrual cycle, consult a doctor immediately. Avoid risk factors, treat emerging diseases in time. Lead an active lifestyle, provide adequate adequate physical activity, temper, get rid of bad habits.

    Interviewed by: Enver Aliyev

    The editors recommend:

    Ovarian cyst: what is it and how to treat it?

    What does an MRI of the small pelvis show in women?

    Fear has big eyes.Is myoma so dangerous?

    For information:

    Dobrenko Alexandra Alekseevna.

    In 2013 she graduated from the Tula State University with a degree in General Medicine. In 2015, she graduated from residency (Russian Scientific Center for Roentgenoradiology) with a degree in Obstetrics.

    Continuing education – Tula State University, specialty “Oncology”, 2016.

    Malafeeva Olga Evgenievna

    Graduated from the Ivanovo State Medical Institute in 1990, Faculty of General Medicine.

    In 1991 she graduated from the internship in the specialty “Obstetrics and Gynecology”. Doctor of the highest category.

    90,000 How and when does menopause occur? | QUESTION-ANSWER

    “At present, the average life expectancy of women has reached 76 years,” explains obstetrician-gynecologist Tatyana Ustinova . – In this case, menopause, that is, the cessation of menstruation, occurs at the age of 50-51. Thus, a third of life is spent in a postmenopausal state. Therefore, it is important to maintain both physical and psychological health in adulthood.

    From the age of 40, women produce less and less female sex hormones – estrogens. During this period, menstrual irregularities, abnormal uterine bleeding may appear. At an appointment with a gynecologist, diseases such as fibroids, endometriosis of the uterus are often detected. But menopause is not a disease. This is a genetically programmed biological stage in the life of any woman, and there is no need to be afraid of it.

    Timely menopause occurs between the ages of 45 and 55.In women who smoke, on average two years earlier, in those who have undergone ovarian surgery, an earlier onset of menopause is also possible. 90% of women during this period experience symptoms associated with estrogen deficiency. These are the so-called vasomotor symptoms: hot flushes, fever in the face and in the upper half of the body, sweating, especially at night, insomnia and other sleep disturbances, tingling and cramps in the limbs. Psychological problems often arise – causeless anxiety, anxiety, irritability, panic attacks, fatigue and depression, memory impairment and concentration, visual impairment, apathy, weakness and decreased libido often occur.Later, the symptoms of genital aging join – dryness and burning, itching in the vagina, frequent and painful urination, soreness during sexual activity.

    It is important to remember that estrogen deficiency increases blood cholesterol levels and peripheral vasospasm, and this increases the risk of cardiovascular disease. Long-term deficiency of sex hormones leads to a gradual increase in blood pressure, contributes to the development of atherosclerosis and increases the risk of coronary heart disease and strokes.The metabolic rate decreases, and often there is a significant weight gain, the likelihood of developing diabetes increases. The mineral plane of the bones decreases, and the risks of osteoporosis and associated fractures increase, as well as the risks of developing senile dementia.

    If you are faced with such a problem, do not self-medicate and do not tolerate symptoms. Sign up for a consultation with a gynecologist. There is now an effective treatment for the symptoms of menopause.