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Dinu MD, Haj Hamoud B, Amza M, Gorecki GP, Sima RM, Gică N, Pleș L. Endometriosis in Menopausal Women-A New Age Is Coming? Literature Review. Life (Basel) 2024; 14:485. [PMID: 38672755 PMCID: PMC11051166 DOI: 10.3390/life14040485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/03/2024] [Accepted: 04/06/2024] [Indexed: 04/28/2024] Open
Abstract
Endometriosis is a chronic inflammatory disease, characterized by the presence of ectopic endometrial tissue, that leads to dysmenorrhea, painful intercourse and infertility. The shift in paradigm from the previous belief that endometriosis exclusively impacts women of reproductive age has brought attention to the condition in both premenarchal and postmenopausal women. Currently, 2-4% of postmenopausal women have endometriosis. Many women experience menopausal symptoms during the peri- and postmenopausal periods and require extensive investigations and monitoring in order to avoid the recurrence of endometriosis symptoms or the risk of malignant transformation when treatment with menopausal hormones is elected. Our goal was to compile and present a clear and concise overview of the existing literature on postmenopausal endometriosis, offering an up-to-date and precise summary of the available information.
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Affiliation(s)
- Mihai-Daniel Dinu
- Department PhD, IOSUD, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (M.-D.D.); (M.A.)
| | - Bashar Haj Hamoud
- Department for Gynecology, Obstetrics and Reproductive Medicine, Saarland University Hospital, Kirrberger Straße 100, Building 9, 66421 Homburg, Germany;
| | - Mihaela Amza
- Department PhD, IOSUD, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (M.-D.D.); (M.A.)
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (N.G.); (L.P.)
- “Bucur” Maternity, Saint John Hospital, 012361 Bucharest, Romania
| | | | - Romina-Marina Sima
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (N.G.); (L.P.)
- “Bucur” Maternity, Saint John Hospital, 012361 Bucharest, Romania
| | - Nicolae Gică
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (N.G.); (L.P.)
- Filantropia Clinical Hospital Bucharest, 011132 Bucharest, Romania
| | - Liana Pleș
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (N.G.); (L.P.)
- “Bucur” Maternity, Saint John Hospital, 012361 Bucharest, Romania
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Abstract
PURPOSE OF REVIEW Postmenopausal endometriosis is a gynecologic disease, affecting 2-5% of postmenopausal woman. Current literature assessing the prevalence, pathogenesis, and treatment of this uncommon condition is limited, stressing the necessity for future research. This review examines the current literature on postmenopausal endometriosis to help inform clinical decision-making and point to novel approaches for treatment and management. RECENT FINDINGS Although one unifying theory to explain the pathogenesis of endometriotic lesions has not been elucidated, estrogen dependence is central to the pathophysiological process. The total quantity of estrogen production is mediated by multiple enzymes in complex pathways. Recent studies have confirmed the presence of these necessary enzymes in endometriotic lesions thereby suggesting a local source of estrogen and a likely pathogenic contributor. More research is needed to fully elucidate the mechanism of local estrogen biosynthesis; however, the current data provide possible explanations for the presence of postmenopausal endometriosis in an otherwise systemically hypoestrogenic environment. SUMMARY All suspected endometriosis lesions should be surgically excised for optimization of treatment and prevention of malignant transformation. If hormone replacement therapy is initiated, combined estrogen and progestin is recommended, even in the setting of previous hysterectomy, given the risk of disease reactivation and malignant transformation of endometriotic lesions. Further research is needed to understand the true prevalence, cause, and progression in this patient demographic. Histologic studies evaluating tissue lesions and peritoneal fluid for estrogen receptors, estrogen metabolizing enzymes, immune cells, and nerve fibers will aide in clinical management and treatment planning.
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de Almeida Asencio F, Ribeiro HA, Ayrosa Ribeiro P, Malzoni M, Adamyan L, Ussia A, Gomel V, Martin DC, Koninckx PR. Symptomatic endometriosis developing several years after menopause in the absence of increased circulating estrogen concentrations: a systematic review and seven case reports. ACTA ACUST UNITED AC 2019. [DOI: 10.1186/s10397-019-1056-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Abstract
Background
To review women with symptomatic and clinically progressive endometriosis after menopause in the absence of estrogen intake or excessive systemic endogenous production.
Design
Seven case reports and a systematic review of the literature from 1995 till February 2018.
Results
Only 7 case reports from the authors and 29 cases from the literature described women with either cystic ovarian or deep endometriosis. Severity, symptoms, and localization are highly variable. No case report describes symptomatic superficial typical lesions. In 22 of 36 women (61%), symptoms started more than 10 years after menopause.
Conclusions
Symptomatic and clinically progressive endometriosis after menopause in the absence of increased systemic estrogen concentrations or exogenous estrogen intake starts more than 10 years after menopause in the majority of women. This observation suggests that a genetic and/or epigenetic incident caused estrogen-independent progression, increased sensitivity to estrogens or increased local production of estrogens. This observation is important for understanding the pathophysiology of endometriosis, for the management of postmenopausal endometriosis, and for individualization of medical therapy of endometriosis since estrogen-independent endometriosis growth probably also occurs before menopause.
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Tan DA, Almaria MJG. Postmenopausal endometriosis: drawing a clearer clinical picture. Climacteric 2018; 21:249-255. [DOI: 10.1080/13697137.2018.1450855] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- D. A. Tan
- Section of Reproductive Medicine, Department of Obstetrics and Gynecology, St. Luke’s Medical Center-Quezon City, Quezon City, Philippines
| | - M. J. G. Almaria
- Section of Reproductive Medicine, Department of Obstetrics and Gynecology, St. Luke’s Medical Center-Quezon City, Quezon City, Philippines
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Suchońska B, Gajewska M, Zyguła A, Wielgoś M. Endometriosis resembling endometrial cancer in a postmenopausal patient. Climacteric 2017; 21:88-91. [PMID: 29166801 DOI: 10.1080/13697137.2017.1398229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Endometriosis occurs in 2-4% of postmenopausal women. There have been a few reports of endometriosis in women in whom neither history nor diagnostic imaging indicated the presence of this disease, either at reproductive age or after menopause. A case is described of an 84-year-old patient with extensive deep pelvic endometriosis imitating advanced neoplastic process.
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Affiliation(s)
- B Suchońska
- a 1st Department of Obstetrics and Gynecology , Warsaw Medical University , Warsaw , Poland
| | - M Gajewska
- a 1st Department of Obstetrics and Gynecology , Warsaw Medical University , Warsaw , Poland
| | - A Zyguła
- a 1st Department of Obstetrics and Gynecology , Warsaw Medical University , Warsaw , Poland
| | - M Wielgoś
- a 1st Department of Obstetrics and Gynecology , Warsaw Medical University , Warsaw , Poland
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Streuli I, Gaitzsch H, Wenger JM, Petignat P. Endometriosis after menopause: physiopathology and management of an uncommon condition. Climacteric 2017; 20:138-143. [PMID: 28286987 DOI: 10.1080/13697137.2017.1284781] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Endometriosis is a hormone-dependent inflammatory disease that is usually characterized by infertility and pain symptoms. This disease mainly occurs during the reproductive years and is rarely diagnosed after menopause. We discuss the physiopathology of this condition after menopause as well as treatment options and the risk of malignant transformation. Occurrence or progression of postmenopausal endometriosis lesions could be related to extra-ovarian production of estrogen by endometriosis lesions and adipose tissue, which becomes the major estrogen-producing tissue after menopause. Postmenopausal women with symptomatic endometriosis should be managed surgically because of the risk of malignancy; medical treatments can be used in cases of pain recurrence after surgery. Aromatase inhibitors act by decreasing extra-ovarian estrogen production and by blocking the feed-forward stimulation loop between inflammation and aromatase within endometriosis lesions. The evidence is currently insufficient to support a conclusion about the optimal hormone replacement therapy for women with endometriosis. The question of malignant transformation of endometriosis in response to hormone replacement therapy in women with a history of endometriosis remains unanswered and needs a long-term follow-up study to evaluate the risk of an adverse outcome. Further studies should be performed to determine the optimal management of menopausal women with endometriosis.
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Affiliation(s)
- I Streuli
- a Department of Gynecology and Obstetrics , University Hospitals of Geneva , Geneva , Switzerland
| | - H Gaitzsch
- a Department of Gynecology and Obstetrics , University Hospitals of Geneva , Geneva , Switzerland
| | - J-M Wenger
- a Department of Gynecology and Obstetrics , University Hospitals of Geneva , Geneva , Switzerland
| | - P Petignat
- a Department of Gynecology and Obstetrics , University Hospitals of Geneva , Geneva , Switzerland
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Morassutto C, Monasta L, Ricci G, Barbone F, Ronfani L. Incidence and Estimated Prevalence of Endometriosis and Adenomyosis in Northeast Italy: A Data Linkage Study. PLoS One 2016; 11:e0154227. [PMID: 27101396 PMCID: PMC4839734 DOI: 10.1371/journal.pone.0154227] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 04/11/2016] [Indexed: 01/12/2023] Open
Abstract
Despite being quite frequent and having serious implications in terms of symptomatology and fertility, data on incidence and prevalence of endometriosis and adenomyosis following gold standard definitions are dramatically lacking. The average time from onset of symptoms to diagnosis in industrialized countries still ranges from five to ten years. Using the regional centralized data linkage system, we calculated incidence and prevalence of endometriosis and adenomyosis in the female population of Friuli Venezia Giulia region, Italy, for the years 2011-2013. Cases were defined as new diagnoses from hospital discharge records, following procedures allowing direct visualization for endometriosis and hysterectomy for adenomyosis, with or without histological confirmation. Diagnoses were considered "new" after verifying women had not been diagnosed in the previous ten years. Incidence of endometriosis and adenomyosis in women aged 15-50 years is 0.14%. Prevalence, estimated from incidence, is 2.00%. Adenomyosis, representing 28% of all diagnoses, becomes increasingly prevalent after the age of 50 years. Our results shows how the study of both endometriosis and adenomyosis should not be limited to women of premenopausal age. Further efforts are needed to sensitize women and health professional, and to find new data linkage possibilities to identify undiagnosed cases.
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Affiliation(s)
- Caterina Morassutto
- Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health–IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Lorenzo Monasta
- Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health–IRCCS “Burlo Garofolo”, Trieste, Italy
- * E-mail:
| | - Giuseppe Ricci
- Department of Obstetrics and Gynecology, Institute for Maternal and Child Health–IRCCS “Burlo Garofolo”, Trieste, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Fabio Barbone
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
- Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - Luca Ronfani
- Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health–IRCCS “Burlo Garofolo”, Trieste, Italy
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The unexpected conundrum of endometrioid carcinoma in deep rectal endometriosis arising 11 years after total hysterectomy bilateral salpingo-oophorectomy. Int J Colorectal Dis 2016; 31:475-7. [PMID: 25805319 DOI: 10.1007/s00384-015-2188-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2015] [Indexed: 02/04/2023]
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Bassi MA, Arias V, D'Amico Filho N, Gueuvoghlanian-Silva BY, Abrao MS, Podgaec S. Deep Invasive Endometriosis Lesions of the Rectosigmoid May Be Related to Alterations in Cell Kinetics. Reprod Sci 2015; 22:1122-8. [PMID: 25721913 DOI: 10.1177/1933719115574341] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aim of this study was to analyze cell kinetics through expression and apoptosis of topoisomerase 2-α (TOP2A), p53, and c-erb2 in rectosigmoid endometriotic lesions and in healthy endometrial tissue and to establish correlations between such findings and clinical data in patients with rectosigmoid endometriosis. METHODS Sixty patients with rectosigmoid endometriosis and 20 control women without endometriosis were included. Immunohistochemical assays were used to measure expression of TOP2A, p53, and c-erB-2. Apoptosis was quantified by directly counting the apoptotic bodies. FINDINGS The number of lesions was positively correlated with expression of TOP2A in the lesion. There was also significant correlation between the lesions' size and number and cell turnover index. Apoptosis index (AI) was the same for endometriosis lesions and eutopic endometrium. Expression of TOP2A was significantly lower in the endometriosis group compared to the controls. CONCLUSIONS Changes in cell proliferation but not in the AI in rectosigmoid endometriosis are indicative of an imbalance in cell kinetics that may lead to the development of the disease.
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Affiliation(s)
- Marco Antonio Bassi
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Sao Paulo, São Paulo, Brazil
| | - Victor Arias
- Department of Pathology, Perola Byington Hospital, São Paulo, Brazil
| | | | | | - Mauricio Simoes Abrao
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Sao Paulo, São Paulo, Brazil
| | - Sergio Podgaec
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Sao Paulo, São Paulo, Brazil Jewish Teaching and Research Institute, Albert Einstein Hospital, São Paulo, Brazil
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Alvarez P, Giudice LC, Levine JD. Impact of surgical excision of lesions on pain in a rat model of endometriosis. Eur J Pain 2014; 19:103-10. [PMID: 24824436 DOI: 10.1002/ejp.527] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic pain is the most common and disabling feature of endometriosis. Surgical excision of endometriosis lesions provides relief but pain relapse is common. Studies in a preclinical model of endometriosis might help to unravel the role of the ectopic lesions as the source of pain. Thus, we evaluated the impact of lesion excision on mechanical hyperalgesia in a preclinical model of endometriosis pain. METHODS Endometriosis was induced by implanting autologous uterine tissue onto the gastrocnemius muscle. Surgical excision or aspiration drainage of the cystic lesion was performed at different times post-implant and mechanical nociceptive thresholds were assessed at the site of the lesion. RESULTS Lesions at 2, 8 and 16 weeks post-implant produced mechanical hyperalgesia of similar magnitude (n = 6/group). Excision of lesions (n = 6/group) produced a longer inhibition, with a magnitude and time course depending upon the timing of excision. Excision at 2 and 8 weeks produced a rapid onset marked attenuation of hyperalgesia, which returned to pre-excision values by post-surgical week 3. In contrast, excision of the lesion at 16 weeks produced a peak of inhibition of hyperalgesia 2 weeks post-excision, but then the inhibition was sustained. Aspiration of fluid from cysts in the lesions briefly attenuated mechanical hyperalgesia (n = 6/group). CONCLUSIONS In this preclinical model, we demonstrate that endometriosis pain is alleviated by surgical excision of the ectopic lesion or drainage of its cysts, providing support for the clinical observation that endometriosis pain is dependent upon the ongoing presence of the lesions.
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Affiliation(s)
- P Alvarez
- Department of Oral and Maxillofacial Surgery, University of California San Francisco, USA; Division of Neuroscience, University of California San Francisco, USA
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Brosens I, Puttemans P, Benagiano G. Endometriosis: a life cycle approach? Am J Obstet Gynecol 2013; 209:307-16. [PMID: 23500453 DOI: 10.1016/j.ajog.2013.03.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 02/16/2013] [Accepted: 03/07/2013] [Indexed: 01/17/2023]
Abstract
To improve the still fragmented understanding of endometriosis, a life cycle approach was adopted that revealed unexpected aspects of the natural history of the disease throughout a woman's life. Three age-related stages of endometriosis are distinguished. In premenarcheal and adolescent endometriosis, 2 types can be distinguished: a classic form that can occur before menarche, and a congenital obstructive form that is caused by uterine anomaly and outflow obstruction. The lesions include superficial peritoneal implants, but adhesions and endometrioma can also occur. It is suggested that premenarcheal and possibly adolescent endometriosis develop by activation of resting stem cells shed at the time of neonatal retrograde uterine bleeding. In the adult, endometriosis can be related to uterine preconditioning by cyclic menstruations acting as a priming mechanism for deep placentation. In adult life, the typical lesions are peritoneal, ovarian, and deep or adenomyotic endometriosis. More recently, endometriosis has been associated with endometrial dysfunction and myometrial junctional zone hyperplasia. These uterine changes can be linked with some major obstetrical syndromes. In postmenopause, endometriosis can develop or be reactivated both in the presence or absence of exogenous estrogens and can spread to a variety of organs and structures causing constrictive lesions.
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Prapas Y, Goudakou M, Matalliotakis I, Kalogeraki A, Matalliotaki C, Panagiotidis Y, Ravanos K, Prapas N. History of endometriosis may adversely affect the outcome in menopausal recipients of sibling oocytes. Reprod Biomed Online 2012; 25:543-8. [DOI: 10.1016/j.rbmo.2012.07.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 07/08/2012] [Accepted: 07/25/2012] [Indexed: 11/15/2022]
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Endometriosis in menopause: a single institution experience. Arch Gynecol Obstet 2012; 286:1571-5. [DOI: 10.1007/s00404-012-2473-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Accepted: 07/11/2012] [Indexed: 10/28/2022]
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Indraccolo U, Barbieri F. Silent onset of postmenopausal endometriosis in a woman with renal failure in hormone replacement therapy: a case report. J Med Case Rep 2010; 4:248. [PMID: 20684788 PMCID: PMC2923173 DOI: 10.1186/1752-1947-4-248] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Accepted: 08/04/2010] [Indexed: 12/03/2022] Open
Abstract
Introduction Postmenopausal endometriosis is a rare form of a common disease, since the absence of estrogenic hormone production should halt disease progression. Case presentation We present the case of a 54-year-old Italian Caucasian woman in surgical menopause with a history of ovarian endometriosis, who underwent voluntary hormone replacement therapy for seven years. She developed postrenal renal failure due to bilateral compression of the pelvic ureteral tract caused by two large, deeply infiltrating endometriotic nodules with no pelvic pain. She underwent operative laparoscopy with adhesiolysis of enteroenteric adhesions and excision of the endometriotic nodules encompassing the juxtavesical tract of the ureters, without obtaining improvement of renal failure. Conclusion Postmenopausal endometriosis can manifest itself in an unpredictable and potentially very serious manner. It is therefore important to carefully evaluate the risks and benefits of administering hormone replacement therapy to patients with previous endometriosis.
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Affiliation(s)
- Ugo Indraccolo
- Maternal-Child Department, Operative Unit of Obstetrics and Gynecology, ULSS 17 - Veneto, Monselice (PD), Italy.
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Palep-Singh M, Gupta S. Endometriosis: associations with menopause, hormone replacement therapy and cancer. ACTA ACUST UNITED AC 2009; 15:169-74. [DOI: 10.1258/mi.2009.009041] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Endometriosis is an estrogen-dependent condition and is characterized by the presence of ectopic endometrial tissue. The pathogenesis of this condition remains an enigma. Endometriosis has well known associations with menopause both in terms of secondary outcomes from medical and surgical therapy in premenopausal women, as well as a natural occurrence/recurrence of the disease in women going through menopause naturally. This review article aims to discuss the current day modalities of management of endometriosis with their pros and cons especially in the context of menopause and cancer.
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Affiliation(s)
- Manisha Palep-Singh
- Department of Gynaecology, Saint Mary's University Hospital, CMMC NHS Trust, Manchester, UK
| | - Sujata Gupta
- Department of Gynaecology, Saint Mary's University Hospital, CMMC NHS Trust, Manchester, UK
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