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.
