Endometriosis in Menopausal Women-A New Age Is Coming? Literature Review

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.

Oestrogen up-regulates DNMT1 and leads to the hypermethylation of RUNX3 in the malignant transformation of ovarian endometriosis

RESEARCH QUESTION

What is the mechanism of hypermethylation of runt-related transcription factor 3 (RUNX3) in the eutopic endometrium of endometriosis as biomarker in the malignant transformation of endometriosis?

DESIGN

Methylation-specific polymerase chain reaction was used to analyse the methylation status of RUNX3 in endometriosis-associated ovarian cancer (EAOC). Primary eutopic endometrial stromal cells (ESC) were isolated from the uteri of patients with ovarian endometriosis. After RUNX3 knockdown by RNA interference technology or ESC treated with oestradiol, the proliferation and invasion ability were evaluated in ESC by using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) and transwell assays.

RESULTS

The frequency of methylation of RUNX3 in neoplastic tissue in the EAOC group was significantly higher than that in the ectopic endometrium of the endometriosis group (P < 0.001), and the frequency of methylation of RUNX3 in the eutopic endometrium of the EAOC group was significantly higher than that in the endometriosis group (P < 0.001). However, there was no significant difference in the eutopic endometrium when compared between the endometriosis group and the control endometrium group (P = 0.233). Silencing RUNX3 promoted the proliferation and invasion of ESC (P < 0.001 and P < 0.001). Following intervention with oestrogen, it was observed that the oestradiol group showed higher levels of RUNX3 methylation (P < 0.001) and DNA methyltransferase 1 (DNMT1) mRNA and protein expression (P < 0.001 and P < 0.001), and lower RUNX3 mRNA and protein expression when compared with the ESC group (P < 0.001 and P < 0.001).

CONCLUSION

This study demonstrated that hypermethylation of the RUNX3 was related to the malignant transformation of endometriosis and that this process was related to corresponding changes in the eutopic endometrium. Furthermore, the 'oestrogen-DNMT1' signalling pathway may induce the hypermethylation of RUNX3 to promote the malignant transformation of endometriosis.

Effect of melatonin for the management of endometriosis: A protocol of systematic review and meta-analysis

BACKGROUND

This study aims to explore the effect of melatonin for the management of endometriosis.

METHODS

We will search electronic databases (Cochrane Library, MEDLINE, EMBASE, CINAHL, Web of Science, Scopus, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure) from their inceptions to the February 29, 2020 without language and publication time limitations. The study identification, study quality assessment, and data extraction will be undertaken by two separate researchers. We will also appraise evidence quality of main outcomes by Grading of Recommendations Assessment Development and Evaluation, and statistical analysis performance by RevMan 5.3 Software.

RESULTS

This study will summarize up-to-date clinical evidence to investigate the effect of melatonin for the management of endometriosis.

CONCLUSION

This study may provide helpful evidence of melatonin for the management of endometriosis.

SYSTEMATIC REVIEW REGISTRATION

INPLASY202040093.

Endometriosis in Menopause-Renewed Attention on a Controversial Disease

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.

The use of Hormone Therapy after Surgery for Endometriosis: An Analysis

Introduction

Estrogen dependence is considered central to the development and progression of endometriosis, which is often viewed as a disease of the premenopausal years, normally regressing after menopause. However, there have been several reports of postmenopausal endometriosis occurring with and without the use of hormone therapy (HT).

Objective

This review aimed to answer the question of whether it is prudent to offer HT for women with a past history of surgical endometriosis. What are the risks? What type of HT should be given?

Methods

A review of the medical literature available in Pubmed, EMBASE, Google scholar, Lilacs, Medline and Cochrane Library databases was performed by selecting articles published in the last ten years, written in any language. The keywords used were endometriosis, menopause, and hormone therapy. In all, 36 articles were found from 2006 to 2016, and their potential relevance to this review was examined. We found 20 literature reviews, 2 retrospective studies, 2 randomized controlled trials and 12 case reports.

Results

There is some risk of endometriosis recurrence after the menopause in patients who receive HT; particularly with estrogen-only therapy.

Conclusions

The existing literature is inadequate to firmly answer our questions. However it is clear that some risk of recurrence exists. Nevertheless, it is suggested that it is reasonable to prescribe HT to women with a history of surgical endometriosis. Recurrences may occur even in the absence of using HT. It is suggested that in women with severe disease the use of estrogen plus progestogen is safer than estrogen alone. Malignant transformation may occur 1% of the time and may be of greater concern with using estrogen alone, warranting close surveillance in all women.

Small bowel obstruction caused by endometriosis in a postmenopausal woman

We report a rare case of small bowel obstruction (SBO) caused by endometriosis in a postmenopausal woman. A 54-year-old postmenopausal woman presented with severe abdominal pain and vomiting. Before menopause, she sometimes had abdominal pain associated with menses. Axial multi-dimensional CT images revealed a SBO with small nodules near the terminal ileum. The obstruction was diagnosed as being caused by small bowel endometriosis. Curved planar reconstruction images showed a complicated obstruction of the small intestine 15 cm from the terminal ileum. Based on the stenotic lesion, a SILS procedure was performed. The patient's SBO diagnosis was histologically confirmed as being caused by small bowel endometriosis. SILS was deemed to be a safe, feasible procedure for treating this bowel obstruction. Curved planar reconstruction images were useful in preoperative imaging and diagnosis of SBO, especially as they were able to highlight the constricting legion.

Predictive factors for the presence of malignant transformation of pelvic endometriosis

OBJECTIVES

To determine predictive factors for the presence of malignant transformation in ovarian endometriotic cysts.

STUDY DESIGN

This was an IRB approved, case control study analyzing patient data from 2004 to 2013. Pathology database records were searched to identify patients with benign endometrioma and ovarian carcinoma arising in the background of endometriosis. Inclusion criteria required each patient to have a preoperative diagnosis of adnexal mass and no other findings concerning for malignancy. Patient clinical records were queried for preoperative symptoms, serum CA125 levels and radiologic findings. Pathologic data were collected including histology, tumor grade and stage.

RESULTS

A total of 138 patients met inclusion criteria; 42 women with ovarian cancer arising in the background of endometriosis and 96 women with benign endometrioma. Women diagnosed with ovarian cancer were significantly older than women with endometriosis (53.6 vs. 39.2 years). There was no difference in presence of symptoms between the two groups. Women with malignant tumors were found to have significantly larger cysts (14 cm vs. 7.5 cm; p<0.0001) that were more often multilocular (45.7% vs. 12.2%; p<0.0001), and contained solid components (77.1% vs. 14.5%; p<0.0001). Among patients that were observed prior to surgery there was a significant difference in the change in size of the mass over time with 4.2 cm increase for cases vs. 1.0 cm increase for controls (p=0.02). Multiple logistic regression analysis indicated that for every 5 years increase in age there was an adjusted OR of 2.17 (p=0.003). An age of 49 years or greater had an 80.6% sensitivity (95% CI: 62.5-92.5%) and an 82.9% specificity (95% CI: 67.9-92.8%) for malignancy, and solid component on imaging had an adjusted OR of 23.7 (p<0.0001). Serum CA125 levels tended to be higher in patients with malignant tumors but did not reach statistical significance with a mean of 204.9 vs. 66.9 (p=0.1).

CONCLUSIONS

Significant predictors for malignant transformation of endometriosis include cyst characteristics and age. Women above the age of 49 with multilocular cysts and solid components are at high risk for malignant transformation of endometriosis. Serum CA125 level is not a significant predictor of malignant transformation.

Geriatric gynecology

Most postmenopausal vaginal bleeding is benign; however, it merits diagnostic evaluation by transvaginal ultrasound or endometrial biopsy after emergency department evaluation. Patients and physicians may treat menopausal symptoms with hormone replacement therapy or other agents, such as venlafaxine or gabapentin. Hormone replacement therapy, when initiated close to the start of menopause and continued at the lowest possible dose for the shortest possible duration, carries less risk than previously believed. Pelvic organ prolapse affects millions of women and may contribute to poor body image and difficulty with urinary, gastrointestinal, and sexual function. Treatment options include Kegel exercises, pessaries, and surgery.