Postmenopausal endometriosis, where are we now?

Camille Ladanyi, C Ladanyi, Ladanyi C, Sarah Boyd, Boyd S, Sticco P, Peter Sticco, Shanti Mohling, S Mohling, Mohling S
Current opinion in obstetrics & gynecology · 2019 · vol. 31(4) , pp. 267–278 · doi:10.1097/gco.0000000000000548 · PMID:31276453 · W2944348016
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This review examines current literature on postmenopausal endometriosis, highlighting estrogen dependence in lesion pathogenesis and recommending surgical excision and specific hormone replacement therapy.

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This review examines the current literature on postmenopausal endometriosis, a condition affecting two to five percent of postmenopausal women, to address gaps in understanding its prevalence and pathogenesis. The authors highlight that estrogen dependence remains central to the disease process, with recent evidence suggesting local estrogen biosynthesis within lesions contributes to pathology despite systemic hypoestrogenism. Clinical recommendations emphasize surgical excision of suspected lesions to prevent malignant transformation and advise combined estrogen-progestin hormone replacement therapy if initiated. This paper is centrally about endometriosis, specifically focusing on the management and pathophysiology of the disease in postmenopausal patients.

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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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Postmenopausal endometriosis, where are we now? - Camille Ladanyi - Sarah Boyd - Peter Sticco - Shanti Mohling 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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Condition tags

endometriosis

MeSH descriptors

Endometriosis Hormone Replacement Therapy Postmenopause Biopsy Cell Transformation, Neoplastic Disease Progression Endometriosis Estrogens Estrogens Estrogens Female Humans Hysterectomy Prevalence Progestins Progestins Progestins Receptors, Estrogen Receptors, Estrogen Treatment Outcome

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