{"paper_id":"1d2bd3f8-ac09-4f42-accd-a47181837159","body_text":"202Copyright © All rights are reserved by Baquedano Mainar L.\nOpen Access Journal of Reproductive \nSystem and Sexual Disorders\nCase Report\n Diagnosis and Management of Vaginal Endometriosis \nInvolvement in Postmenopausal Woman. A Case Report\nBaquedano Mainar L*, Herrero Serrano R, Espiau Romera A, Gabasa Gorgas L, Pallarés Arnal V , Benito Vielba M, \nOrtega Marcilla S and Lamarca Ballesteros M\nDepartment of Gynecology, Miguel Servet University Hospital, Zaragoza, Spain\n*Corresponding author: Laura Baquedano Mainar, Gynecology Department, Paseo Isabel La Catholica 1-3, 50009, Miguel Servet \nUniversity Hospital, Zaragoza, Spain\nReceived: \n  March 01, 2019                                                                                                                                  Published: \n March 07, 2019\n Introduction\nEndometriosis is a pathology which usually occurs during the \nreproductive period and is rarely diagnosed after menopause [1]. \nThe prevalence of postmenopausal endometriosis is around 2-5% \nand it is not known yet whether it is a progression of a previously \nexistent endometriosis or it develops de novo [2]. It is thought that \nthe pathogenic mechanism of postmenopausal endometriosis may \ninvolve “estrogen threshold theory” . According to this theory a \nreactivation of endometriosis islets is produced, even in the lower \nestrogenic menopausal state. Nevertheless, de novo endometriosis \nlesions after menopause can also be produced [3]. The main clinical \nmanifestations consist of endometrial implants, being the pelvic \norgans the most frequent locations. However, different locations of \nendometriosis are described, as cutaneous, intestinal or ureteral \nfoci.\n The management of endometriosis after menopause is still \ncontroversial but, in most cases, the first line of treatment includes \nsurgery [4]. Recurrences are common and second-line drug \ntreatment could be necessary [5]. Although endometriosis is a \n Abstract\nEndometriosis is a pathology which affects up to 10% of the female population in reproductive age characterized by the \npresence of actively functional endometrial ectopic tissue that suffers cyclical changes that are induced by the ovarian hormones, \nwhich produces a chronic inflammatory reaction. This disease occurs during the reproductive years and is rarely diagnosed after \nmenopause.\nCase Report: A 51 years old woman, who had had a unilateral laparoscopic adnexectomy due to an endometrioma one year \nbefore, was admitted because of postmenopausal vaginal bleeding. The medical examination only showed two polypoid formations \nof 1 and 3cm located on posterior vaginal fornix which presented with smooth cystic surface. A histological analysis was carried \nout revealing an endometriotic nature. Despite the bleeding, the patient was asymptomatic, consequently a close monitoring was \nadopted.\nDiscussion: Typically, endometriosis resolves after natural or iatrogenic menopause due to declining estrogen levels. \nNonetheless, case reports over the years have highlighted the incidence of recurrent postmenopausal endometriosis. Occurrence or \nprogression of postmenopausal endometriosis lesions could be related to extra-ovarian production of estrogen by endometriosis \nlesions and adipose tissue, which becomes the major estrogen-producing tissue after menopause. Hormone therapy (HT) may \nreactivate endometriosis and stimulate malignant transformation in women with a history of endometriosis.\nThe risk of malignant transformation of premenopausal endometriosis is around 1%. Furthermore, patients with endometriosis \nhave an increased risk of ovarian cancer and other malignancies. These transformations appear to be further elevated in patients who \ntake HT , although this issue is not fully elucidated. The evidence is currently insufficient to support a conclusion about the optimal \nHT for women with endometriosis. Given the uncertain risks of initiating it, it is laborious to determine the best management.\nConclusión: Vaginal involvement is an atypical endometriosis location, especially in menopausal women, thus close surveillance \nis necessary.\n Keywords: Endometriosis; Menopause; Vaginal Diseases; Vaginal Bleeding\nDOI: 10.32474/OAJRSD.2019.02.000138\nISSN: 2641-1644\n\nCitation: Baquedano Mainar L, Herrero Serrano R, Espiau Romera A, Gabasa Gorgas L, Pallarés Arnal V, et al ., Diagnosis and Management \nof Vaginal Endometriosis Involvement in Postmenopausal Woman. A Case Report. Open Acc J Repro & Sexual Disord 2(3)- 2019. OAJRSD.\nMS.ID.000138. DOI: 10.32474/OAJRSD.2019.02.000138.\n                                                                                                                                                                              Volume 2 - Issue 3Open Acc J Repro & Sexual Disord. Copyrights @ Baquedano Mainar L, et al.\n203\nbenign disease, postmenopausal endometriosis brings an increased \nrisk for malignancy up to 1% of cases. Several cases of neoplasia on \npostmenopausal lesions have been reported, being ovarian cysts \nthe most frequent way in which a malignant lesion can appear. This \nfinding should encourage clinicians to have a close surveillance of \npostmenopausal women who suffer from endometriosis [6]. We \nintroduce an uncommon location of postmenopausal endometriosis \nand its management.\nCase and Methods\nA case of a 51-years-old woman who consulted due to \npostmenopausal bleeding is conducted. Highlighted as personal \nbackground, the patient was Gravida 1 Para 1 (C-section), post-\nmenopausal for 2 years and had rheumatoid arthritis and \ndyslipidemia following treatment with methotrexate and statins. \nThe year before unilateral right laparoscopic adnexectomy was \nperformed due to a five cm expansive cyst diagnosed by magnetic \nresonance (MR). Laparoscopic findings showed a normal uterus \nand left ovary while the right ovary presented a multicystic solid \nformation described as “a bunch of grapes” . The final pathological \nanalysis informed of an endometrioid fibrous lesion. Rest of \nexploration was out of any endometriosis foci. \nAt present time, the patient came at emergency unit with \npostmenopausal vaginal bleeding. The medical examination only \nshowed two polypoid formations of 1 and 3cm located on posterior \nvaginal fornix which presented a smooth cystic surface (Figures 1 \n& 2). The rest of the vaginal exploration was anodyne. Transvaginal \nultrasound showed a 3.5cm intramural-sub serosal leiomyoma \nlocated in the anterior wall of the uterus and a 6.2mm endometrial \nline. No other endometrial implants were found by the ultrasound \nexamination. The pathological analysis of the vaginal injury was \ncarried out revealing its endometrial nature with CD 10 positive \nreaction in peri glandular stromal cells and either estrogen or \nprogesterone receptors in stromal cells and glands. A routinely \nendometrial sample was taken which revealed no proliferative \nactivity and atrophic endometrial mucosae. Despite the bleeding, \nthe patient stayed asymptomatic. Consequently, a close monitoring \nwas adopted to be performed every three months.\nFigure 1: Vaginal lesions discovered in the first examination.\nFigure 2: Vaginal endometriosis maintain stable in a subsequent visit.\n\n\n                                                                                                                                                                              Volume 2 - Issue 3Open Acc J Repro & Sexual Disord.\nCitation: Baquedano Mainar L, Herrero Serrano R, Espiau Romera A, Gabasa Gorgas L, Pallarés Arnal V, et al ., Diagnosis and Management \nof Vaginal Endometriosis Involvement in Postmenopausal Woman. A Case Report. Open Acc J Repro & Sexual Disord 2(3)- 2019. OAJRSD.\nMS.ID.000138. DOI: 10.32474/OAJRSD.2019.02.000138.\nCopyrights @ Baquedano Mainar L, et al.\n204\nDiscussion \nTypically regarded as a premenopausal disease, endometriosis \nresolves after natural or iatrogenic menopause due to declining \nestrogen levels. Nonetheless, case reports over the years \nhave highlighted the incidence of recurrent postmenopausal \nendometriosis. According to these studies, the prevalence of \npostmenopausal endometriosis is 2-5% [7]. Asymptomatic \nendometriosis lesions can be discovered incidentally during pelvic \nimaging or surgical interventions performed on postmenopausal \nwomen for other conditions. Many different locations of \npostmenopausal endometriosis were described [8-10]. Data on \nthe physio pathological mechanisms implicated in postmenopausal \nendometriosis are limited. Postmenopausal endometriosis is even \nmore complex, because it is not known whether it is a continuation \nof a previous disease or it develops de novo. After menopause, \nendometriosis lesions can be stimulated by estrogen from extra-\novarian sources including adipose tissue, the adrenal glands, or an \nexogenous source (e.g. hormone menopause therapy, MHT) [11]. \nAnother mechanism has been suggested is the estrogen production \nby the endometriosis lesions. According to Bulun and colleagues, \naromatase is expressed in endometriosis implants and in the \nectopic endometrium of women with endometriosis; autocrine and \nparacrine effects result in local production of estrogen [12,13].\nThe risk of malignant transformation of premenopausal \nendometriosis is around 1% occurring most commonly in ovarian \nlesions [14]. Furthermore, patients with endometriosis have an \nincreased risk of ovarian cancer and other malignancies. The risk \nof malignant transformation increases after menopause and after \nintroduction of MHT , especially in case of unopposed estrogen \nsubstitution [15]. Since there have been contradictory reports \non postmenopausal HT used in women with previously known \nendometriosis, in 2010, European Menopause and Andropause \nSociety reported a position statement regarding to managing \nmenopause in women with previous history of endometriosis \n[16]. As pointed out in the European Menopause and Andropause \nSociety’s statement, today we accept that hormonal therapy may \nreactivate residual lesions, and the risk of malignant transformation \nof endometriosis had to be considered in postmenopausal women. \nThe most common malignancies associated with endometriosis \nwere endometrioid and clear-cell ovarian cancers [17]. Several \ncases of neoplasia in postmenopausal endometriosis lesions have \nbeen reported in the literature and are summarized in a review \narticle by Soliman, et al. [18].\nFirst line treatment for symptomatic endometriosis in \npostmenopausal patients should be surgical, mainly due to the \nrisk of malignancy. However, surgery in such patients may carry \nsome risks. Firstly, such cases are older when compared with \ncases at reproductive ages, thus may have comorbidities. Secondly, \nthese patients may have previous surgeries, accordingly, may have \nhigher operative risks. Nevertheless, recurrences are common \nafter surgical treatment and second-line drug treatment may be \nnecessary. Medical treatment has been studied in women with \nendometriosis in post menopause. Due to hormonal peripheral \nconversion, aromatase inhibitors may propose a new alternative \nfor postmenopausal patients with endometriosis [19,20].\nConclusion\nVaginal endometriosis in postmenopausal women is an \nextremely rare condition. Malignant transformation seems to \nbe increased. The evidence is currently insufficient to support \nconclusions about the best management in these patients. \nMulticenter studies should be performed about endometriosis and \nmenopause.\nReferences\n1. Tan DA, Almaria MJG (2018) Postmenopausal endometriosis: drawing a \nclearer clinical picture. Climacteric 21(3): 249-255. \n2. Inceboz U (2015) Endometriosis after Menopause. Women’s Heal 11(5): \n711-715. \n3. Streuli I, Gaitzsch H, Wenger JM, Petignat P (2017) Endometriosis \nafter menopause: physiopathology and management of an uncommon \ncondition. Climacteric 20(2): 138-143. \n4. Gemmell LC, Webster KE, Kirtley S, Vincent K, Zondervan KT , et al. \n(2017) The management of menopause in women with a history of \nendometriosis: a systematic review. Hum Reprod Update 23(4): 481-\n500.\n5. Shah D (2012) Postmenopausal endometriosis-a new dimension. \nClimacteric 15(5): 507-508. \n6. Yoldemir T (2018) Quality of life for women with endometriosis: \npremenopausal and postmenopausal perspectives. Climacteric 21(5): \n411-412. \n7. Haas D, Chvatal R, Reichert B, Renner S, Shebl O, et al. (2012) \nEndometriosis: a premenopausal disease? Age pattern in 42,079 \npatients with endometriosis. Arch. Gynecol. Obstet 286(3): 667-670.\n8. Popoutchi P , dos Reis Lemos CR, Silva JC, Nogueira AA, Feres O, et al. \n(2008) Postmenopausal intestinal obstructive endometriosis: case \nreport and review of the literature. Sao Paulo Med. J 126(3): 190-193.\n9. Beuke M, Dahlem R, Fisch M (2006) Distal stenosis of the ureter due \nto extrinsic endometriosis in a postmenopausal woman. Aktuelle Urol \n37(2): 143-144.\n10. Pugliese JM, Peterson AC, Philbrick JH Jr, Allen RC Jr (2006) Ureteral \nendometriosis in patients after total abdominal hysterectomy: \npresentation and diagnosis: a case series. Urology 67(3): 622.e13-15.\n11. Bendon CL, Becker CM (2012) Potential mechanisms of postmenopausal \nendometriosis. Maturitas 72(3): 214-219.\n12. Bulun SE, Yang S, Fang Z, Gurates B, Tamura M, et al. (2002) Estrogen \nproduction and metabolism in endometriosis. Ann N Y Acad Sci 955: \n396-406.\n13. Bulun SE (2009) Endometriosis. N Engl J Med 360: 268-279.\n14. Pollacco J, Sacco K, Portelli M, Schembri-Wismayer P , Calleja-Agius J \n(2012) Molecular links between endometriosis and cancer. Gynecol \nEndocrinol 28(8): 577-581.\n15. Kobayashi H, Sumimoto K, Kitanaka T , Yamada Y, Sado T , et al. (2008) \nOvarian endometrioma-risks factors of ovarian cancer development. \nEur J Obstet Gynecol Reprod Biol 138(2): 187-193.\n16. Moen MH, Rees M, Brincat M, Erel T , Gambacciani M, et al. (2010) \nEuropean Menopause and Andropause Society. EMAS position \n\nCitation: Baquedano Mainar L, Herrero Serrano R, Espiau Romera A, Gabasa Gorgas L, Pallarés Arnal V, et al ., Diagnosis and Management \nof Vaginal Endometriosis Involvement in Postmenopausal Woman. A Case Report. Open Acc J Repro & Sexual Disord 2(3)- 2019. OAJRSD.\nMS.ID.000138. DOI: 10.32474/OAJRSD.2019.02.000138.\n                       Volume 2 - Issue 3Open Acc J Repro & Sexual Disord. Copyrights @ Baquedano Mainar L, et al.\n205\nstatement: managing the menopause in women with a past history of \nendometriosis. Maturitas 67(1): 94-97.\n17. Zanetta GM, Webb MJ, Li H, Keeney GL (2000) Hyperestrogenism: a \nrelevant risk factor for the development of cancer from endometriosis. \nGynecol Oncol 79(1): 18-22.\n18. Soliman NF, Hillard TC. (2006) Hormone replacement therapy in women \nwith past history of endometriosis. Climacteric 9(5): 325-335.\n19. Special report (2015) Endometriosis after menopause. Women’s Health \n11(5): 711-715.\n20. Attar E, Bulun SE (2006) Aromatase inhibitors: the next generation of \ntherapeutics for endometriosis? Fertil. Steril 85(5): 1307-1318.\n Open Access Journal of Reproductive System and \nSexual Disorders\nAssets of Publishing with us\n• Global archiving of articles\n• Immediate, unrestricted online access\n• Rigorous Peer Review Process\n• Authors Retain Copyrights\n• Unique DOI for all articles\nThis work is licensed under Creative\nCommons Attribution 4.0 License\nSubmission Link:         \n        \n        \n        \nSubmit Article\nDOI: 10.32474/OAJRSD.2019.02.000138","source_license":"CC0","license_restricted":false}