POST MENOPAUSAL ENDOMETRIOSIS

FREQUENCY, DIAGNOSIS AND MANAGEMENT

Endometriosis a common gynaecological disorder occurring in 5 to 10% of the female population. It is a disease that affects younger women during their fertile life. It is supposed to be oestrogen dependent and therefore subsides after menopause. However it still occurs in 2.5 % of post menopausal women. Now there are millions and millions of postmenopausal women, and thousands are with Endometriosis, thus the gynaecologists often come across them. In recent times management of postmenopausal endometriosis is being considered. There is no clear cut pathogenesis on endometriosis. A very old retrograde menstruation theory does not explain all situations. In some case endometriosis has been seen in some 60 to 70 year old women, without any previous history. These lesions are deep, adhesive and sometimes far off from the pelvis. Besides retrograde menstruation, the other factors can be familial predisposition, genetic and epigenetic factors. It can also happen because of coelomic metaplasia, (meaning the bowel epithelium changes into endometriotic tissue) It can also arise from foetal remnants or abnormal oestrogen production from non ovarian tissues. Perhaps immune deficiency also plays a role it is believed that a hormone called Aromatase can convert the local testosterone into oestrogens and a de novo endometriosis arises. Levels of this hormones are higher in postmenopausal women . This can happen more often in obese women. No single theory can explain endometriosis especially when it happens for the first time. It often happens away from the pelvis on non gonodal (not gonads) such as, organs, kidney, ureter (the tube that connects the kidney to the bladder), appendix and bowel. Very rarely it is even reported on the skin. HRT is often responsible for postmenopausal endometriosis especially if oestrogen only therapy is used. Phytoestrogens (oestrogens from plant sources), these are over the counter drugs and their irregular use can reactivate endometriosis in post menopausal women who had it in younger years. Previous endometriosis can even become malignant if oestrogen only therapy is used in hysterectomised post menopausal women.

When women suffer, with pelvic pain, dyspareunia, Dyschezia (pain on bowel movement), abnormal bleeding, and known to have had endometriosis, has had surgical treatment, even if no history of endometriosis, always keep endometriosis in mind. Now if a woman is still having hot flushes, foggy head, lack of sleep and requests treatment for her problems; what can be offered to help her? After looking at her basic previous history, tests such as, a pelvic examination, cytology basic blood tests, maybe an ultrasound, a laparoscopy, if the pain is significant. If there are any significant findings, such as cysts on the ovary and deep infiltrating endometriosis, surgical treatment is advised. If there are no surgical findings medical treatment can be offered. This can be in the form of oestrogens, progesterone, and modified oestrogens called SERMS (modified oestrogens which act differently on different organs). If she still has her uterus and has recently become postmenopausal, concerned about pregnancy, she can try an oral contraceptive pill. Use a pill that best suits her. She can also try a group of hormones called GnRH analogues (these can lower the sex hormone levels). Tibolone, a synthetic steroid which acts as oestrogen, progesterone and testosterone, is a very useful drug. It helps with hot flushes, decreased libido and is very easy to take. It is a useful HRT for postmenopausal with endometriosis. It has a slightly increase risk of DVT.

Postmenopausal endometriosis is mostly recurrence or continuation of premenopausal endometriosis however there are cases reported which seem to arise new. There pathophysiology is difficult to understand.  Beside the explanations mentioned earlier it is also believed that an inflammatory  small cell protein involved in cell signalling called interlukin  play an important role by allowing ectopic endometrial cells to implant in different places and help them to grow. It is also suggested that stem cells modify as endometrial cells.

Conclusion: - Postmenopausal endometriosis is known to occur in about 2.5% of this group of women. It should always be kept in mind when postmenopausal women present with symptoms of pain and / or abnormal bleeding.

Since the postmenopausal endometriosis can be malignant, they can be surface ovarian cancers, endometrial and clear cell cancers; surgical treatment should be the first line of approach.  Many case reports where endometriosis is seen to occur outside the pelvis, such as the ureter, appendix, and bowel loops, and vagina. In one recent case report on the liver in which after surgical treatment, a SERM (conjugated equine oestrogens/ Bazidoxifene,) was used, as a modified HRT which preventing oestrogen acting on the endometrium (preventing the risk of endomtrial cancer), was used, and endometriosis completely resolved. I wonder if in future others will try to do this. Further research is needed to manage the postmenopausal Endometriosis and guidelines for surgical treatment and different newer HRT, will also be very welcome.

BOY OR GIRL? IT DEPENDS ON THE MALE PARTNER

This story starts in 1962. I was a very young doctor, just started a new job at a newly opened Medical school as a lecturer. It was my very first day, at my first job after completing my training. Those days there was no ultrasound, not even an x-ray machine nearby. My registrar called me to this new admission in the labour ward a woman was in established labour, who had never seen a doctor throughout her entire pregnancy. She had an enormous belly. It was difficult to feel anything. I expected it to be a twin pregnancy with too much fluid. We had no idea about her blood count. She told us she is trying for a male child and already has six daughters .Within minutes of her arrival the first child was born, the second child was already in a big hurry to arrive in the world , her belly was still somewhat biggish, however I gave her the injections to prevent bleeding which  is given after twin birth, then suddenly I realised that there was another baby, I had never witnessed  a triplet birth and never thought of it, we rushed a bit, to save getting  this baby trapped  after the injection, but luckily this baby arrived safely. Guess what, all the babies were girls well formed all normal with good weights between 4.5 lbs to 5 lbs. I suddenly felt very sad. I did not know how to tell the parents I told them of a family who had 8 daughters hoping for a son one day they all became very successful doctors. Here with this lower middle class family I was worried about their feeding and schooling.  60 years on, since I still think of what happened to them. In some countries there is such a fanaticism about having a son to carry the family name. Sadly the women are always blamed however it is the fathers Y chromosome which is responsible for the sex of the baby. In humans there are two sex chromosomes X and Y. The females have XX and male are XY. When a baby is being formed, an X chromosome comes from the mother and Y from the father, if there is a Y chromosome then the baby will be male. There is a 50 /50 chance in nature what will happen.  There are a few theories. The sperm can be male or female depending on what a particular man has inherited. The male are divided as mm, mf, and ff, men with mm sperm will mostly have boys and ff will mostly have girls. This varies in different generations.  The female sperm is longer stronger and also lives longer so a few theories were suggested that if you want to have a female child work out your ovulation and refrain from having sex two to three days before that, by the time you ovulate your male sperms may have demised, and if you want a male child have sex as close to ovulation as possible the fast running sperm will be able to fertilize the egg. In the 21^st century ovulation can be worked out by temperature charts, and ultrasounds, even an artificial inoculation of sperm can be done on the precise day. This in my very brief experience proved excellent. In more sophisticated medical situations where sexing is required for prevention of sex linked diseases, a micro sort system is recommended in preference to per implantation biopsy and intra villous sampling. Stories also go about what position you adopt during sex for a boy or girl. Inherited billionaires have more boys. People who have more brothers have more sons and vice versa. How do we guess in modern times when everybody has only one or two siblings? To my way of thinking the ovulation technique seems more scientific. Poor King Henry the VIII was not aware of any of this, and that it was he who was responsible for the sex of his child and not his queens.