Postmenopausal endometriosis

Untreated symptomatic endometriosis has adverse life impacts: achievements, education, family, career, social life, personal relationships, emotional health, and quality of life starting at adolescence and occurring even beyond menopause. Impaired daily activities, fatigue, sexual dysfunction, physical changes due to treatment, emotional distress, depression, anxiety, and comorbidities lead to worsen quality of life [Citation1]. While endometriosis is seen in almost 10% of women during perimenopausal years, its prevalence after menopause is estimated to be 2–4%. One of the differential diagnoses of pelvic pain in postmenopausal women is endometriosis. Postmenopausal endometriosis might occur de novo in women who never had endometriosis symptoms or may recur after the initiation or continuation of menopausal hormonal therapy (MHT) [Citation2]. Endometriosis lesion can affect different organs such as the bladder, ureter, intestines, and thorax. The recurrence of postmenopausal endometriosis might be seen after estrogen-only or estrogen combined with progestin MHT [Citation3]. Recurrence has been reported with low-dose, standard dose, high dose estrogen alone and also combined estrogen and progestogen regimens. Similarly, recurrence has also been seen with the use of low and standard dose tibolone [Citation2]. When endometriosis recurs in the postmenopausal period, the common symptoms are flank and pelvic pain, vaginal bleeding and dyspareunia. Malignant transformation of endometriotic foci might be seen after MHT in women with a history of endometriosis [Citation4]. Patients in the published case reports and case series display symptoms related to the type, site, and extent of malignancy. Common findings were abdominal and pelvic pain, vaginal and rectal bleeding, and hematuria. Any location can be affected by malignancy such as the bladder, cervix, ovary, rectum, ureter, and vaginal vault. Endometrioid adenocarcinoma was by far the most commonly diagnosed MHT-associated malignancy. The risk of ovarian and thyroid cancer is 1.3% in all women, whereas this risk is increased to 2.5% and 1.8%, respectively in women with endometriosis. Breast cancer risk is also increased from an overall of 12.8% to 13.3% in those with endometriosis. The increase in the risk in these three cancer types is not significant, thus the recommended screening intervals do not warrant more frequency [Citation3,Citation4]. The most likely ovarian cancer subtypes are clear cell, endometrioid, and low-grade serous tumors [Citation4]. Atypical endometriomas have a higher risk of malignant transformation. Current guidelines do not recommend bilateral salpingo-oophorectomy to prevent ovarian cancer in women with endometriosis [Citation3]. A minimum of one pelvic ultrasound is recommended per year to monitor the change in size of endometriomas [Citation3]. If the size increases or an endocystic papillary formation inside the endometrioma shows vascularity then surgical excision is suggested. For deep infiltrating endometriosis an initial follow-up magnetic resonance imaging (MRI) in 6 months, followed by individualized intervals depending on the results should be considered [Citation5]. If minimal changes are noted, a repeat MRI in two to three years should be scheduled. If there is evidence of change in size or features of the lesions at 6 months, continued close surveillance with repeat MRI in 6 to 12 months should be recommended [Citation3]. Surgery is indicated in postmenopausal women when there are anatomical concerns like ureteral or bowel obstruction, or the presence of pelvic pain resistant to medical therapy, or for the symptomatic relief and management of complications arising from pelvic adhesions, endometriomas, deep infiltrating endometriosis, or identification of suspicious adnexal mass to rule out malignancy [Citation3]. Women with a history of endometriosis should consume unprocessed or processed red meat, dairy products, and dietary fat in the least quantity. Dietary fiber, seaweed, grapes, berries, turmeric, green tea, and cannabinoids are beneficial for relieving endometriosis symptoms. Additionally, vitamins D, C, and E, have anti-inflammatory and antioxidant activity which might reduce endometriosis symptoms. Postmenopausal women who experience endometriosis-like symptoms after they start an MHT should seek medical attention. An individual who wishes to use MHT should be evaluated regarding her previous history of endometriosis, disease severity, family history, comorbidities, and menopausal symptoms. After counseling the woman in relation to the possibility of malignant transformation of the disease and the minimal increased risks of ovarian, breast, and thyroid cancer with the use of MHT, different treatment options can be offered. The choice of MHT can be either a combined estrogen + progesterone/progestin preparation, or a tissue-selective estrogen complex combined with conjugated estrogen. Also, tibolone can be used. The objective of MHT is to increase women’s quality of life by ameliorating endometriosis-related symptoms. Cognitive behavioral therapy, hypnotherapy, selected antidepressants (i.e. paroxetine, venlafaxine, escitalopram, citalopram), gabapentin, and selective neurokinin-1,3 receptor antagonists are other options for non-hormonal treatment of vasomotor symptoms. If women with previous endometriosis, who displayed symptoms that resolved during menopausal transition, develop pelvic pain while on sequential MHT, they might either discontinue the MHT, or lower the estrogen dose, or increase the progestogen dose. Other options are or switching the type or dose of the treatment, or replacing with continuous MHT. Oral combined MHT can be given as conjugated equine estrogens or estradiol coupled with micronized progesterone, dienogest, drospirenone, dydrogesterone, or norethisterone acetate. Transdermal route can be applied with 17 beta-estradiol paired with transdermal norethisterone acetate, or oral or vaginal micronized progesterone, or oral dydrogesterone. Transcutaneous gel or spray of 17 beta-estradiol can be used together with oral or vaginal micronized progesterone, or oral dydrogesterone. A 20µ levonorgestrel intrauterine system can be complemented with transdermal patch or a transcutaneous gel or spray. Women with history of endometriosis should be informed on the possible risks of disease recurrence, malignant transformation of endometriotic foci, and/or the development of some cancers (i.e. breast and ovarian cancers). They should be advised to actively engage in the decision-making process for the use of MHT to alleviate menopausal and endometriosis related symptoms. Department of Obstetrics and Gynecology, Marmara University School of Medicine, Istanbul, Turkey [email protected] Data availability statement All data for this editorial were extracted from previously published studies or openly available data-sets, thus they are publicly available. Additional information Funding References - Yoldemir T. Quality of life for women with endometriosis: premenopausal and postmenopausal perspectives. Climacteric. 2018;21(5):411–412. doi:10.1080/13697137.2018.1511344. - Yoldemir T. MHT in menopausal women at risk: comorbidity endometriosis. Maturitas. 2019;124:119. doi:10.1016/j.maturitas.2019.04.030. - Yoldemir T. Evaluation and management of endometriosis. Climacteric. 2023;26(3):248–255. doi:10.1080/13697137.2023.2190882. - Ozyurek ES, Yoldemir T, Kalkan U. Surgical challenges in the treatment of perimenopausal and postmenopausal endometriosis. Climacteric. 2018;21(4):385–390. doi:10.1080/13697137.2018.1439913. - Cimsit C, Yoldemir T, Guclu M, et al. Susceptibility-weighted magnetic resonance imaging for the evaluation of deep infiltrating endometriosis: preliminary results. Acta Radiol. 2016;57(7):878–885. doi:10.1177/0284185115602147.