This document discusses menopause and endometriosis. Some key points:
1. Endometriosis is an estrogen-dependent condition that typically presents during reproductive years but can occasionally present during or after menopause.
2. At menopause, decreased estrogen levels usually lead to regression of endometriotic lesions and reduced pain.
3. Post-menopausal endometriosis is dependent on extra-ovarian estrogen sources and can occur as persistence of pre-existing disease or develop de novo.
4. Diagnosis requires laparoscopy and histological confirmation of endometriotic lesions. Imaging like ultrasound and MRI can help identify locations like ovarian cysts.
2. Introduction
• A chronic inflammatory disease requires life long management.
• An Estrogen dependent condition of women in their reproductive
years.
• Begins in menarche or early adulthood, rarely presents at
menopause.
• May present at menopause as continuation of existing dis.or as a
DeNovo lesion.
• Women with endometriosis may have natural or premature,early or
age appropriate menopause or surgical or medical menopause.
3. • Hypoestrogenísm at menopause leads to regression of endometriotic
lesions and alleviation of pain.
• Same seen during pregnancy and in drug induced pseudo
menopause.
• Occurrence of De Novo lesion also reported in menopause.
• Asymptomatic lesions incidentally discovered during imaging or
surgery for other reasons.
4. Definition
• As an inflammatory condition characterized by endometrium
like tissue at sites outside uterus.
• Chronic condition of reproductive age associated with
• 1. Debilitating pelvic pain 5. Dysmenorrhoea
• 2. Dyspareunia 6. Infertility.
• 3. Dysuria
• 4 .Dyschezia
5. Classification
• Classified as
• 1. Superficial
• 2. Ovarian
• 3. Deeply infiltrating endometriosis or DIE.
• when endometriotic tissue penetrates retroperitoneal space for a
distance of 5mm or more.
• May present in multiple locations
• 1. In uterus Adenomyosis
6. • 2. In Ovary Endometrioma
• 3. Can occur pelvic peritoneum, Bladder/ Ureter, Rectum, colon,
uterosacral ligaments,rectovaginal septum,vaginal wall, pouch of
douglas.
• 4. Rare locations..distant sites lungs,liver,pancreas,operative
scars,inguinal region a.nd even brain .
• Rectosigmoid is most common site for extra pelvic endometriosis.
• Ovaries are the most common location of endometriotic lesions in
postmenopausal women.
7. • According to severity Amrican society of Reproductive Medicine
staging
• 1. Stage 1 Minimal
• 2. Stage 2 Mild
• 3. Stage 3 Moderate
• 4. Stage 4 Severe
8. Post Menopause & Endometriosis
• Prevalence less than 3%.
• 2-5% of postmenopausal women diagnosed with endometriosis.
• within 7 years of their menopause.
• PATHOGENESIS of ENDOMETRIOSIS AFTER MENOPAUSE
• Presence of Estrogen a central mechanism.
• The leading Estrogen found in these pts is ESTRONE.
9. • Post Menopausal Endometriosis dependent on extra ovarian
Estrogen.
• Occurs either as persistence of pre existing premenopausal
disease or
• May develop as de novo dis .
• EXTRA OVARIAN ESTROGEN may be from
• 1. Through Metaplasia, Induction of Endometriotic Implants thru
continued gonadal steroidogenesis.
• 2.Exogenous Estrogen administration or intake of phytoestrogens.
• 3. Peripheral aromatisation by adipose tissue
• 4. In situ aromatisation in endometriotic tissue.
• 5. H/O Tamoxifen treatment.
• 6. A theory of Estrogen Threshold that is when a certain level of
Estrogen surpassed it activates undetected or transient foci of
endometriosis .
10. Diagnosis
• Symptoms… In postmenopausal women
• 1. Low back or rectal pain
• Painful defecation
• Deep Dyspareunia
• Rectal/ Vaginal Bleeding
• Haematuria
• Hydronephrosis
• Renal failure
• Endometriosis is a disease of late diagnosis.
11. • Specific Biomarkers or Imaging criterias still lacking .
• CA125 non specific tumor marker elevated in endometriosis and
bowel dis.and varies according to menstrual cycle status and in
malignancies.
12. • Only reliable Diagnosis of ENDOMETRIOSIS is Diagnostic Laproscopy
with inspection of abdominal cavity and histological confirmation.
• Macroscopically recognised endometriotic lesions are not
histologically confirmed.
1. Conversely occult microscopic endometriosis can be detected in
biopsies of normal peritoneum of women with or Without visible
lesions.
13. • Ultrasonography and MRI helpful in diagnosis.
• Pelvic scan 1st line of investigation . Helpful in particular diagnosis of
ovarian endometriosis and deep infiltrating Endometriosis.
• TVS has role in assessing involvement of bladder and rectum.
• MRI helpful in diagnosing Adenomyosis and differentiating
Endometriosis from malignancies.
• Useful in evaluation of ureter and expanded pelvic adhesions.
14. Endometrioma on TVS
• 1. Unilocular cyst
• 2. Most often Homogeneous ground glass appearance.
• 3. Indicative of moderate to advanced stage disease.
• 4. Postmenopausal women in whom ovarian cysts with a ground –
glass appearance are associated with a 44% risk of malignancy.
15. • CT plays a major role in diagnosis of bowel endometriosis.,
• Sonovaginography using saline solution or gel infusion is new
diagnostic method in DIE.
• Saline contrast sonovaginography with TVS offers complete view of
vaginal wall,fornix,pouch of Douglas , uterosacral ligaments and
rectovaginal septum.
16. Endometriosis and early age at Menopause
. OVARIAN Reserve reduced
. Controversial to say whether Endometriosis reduces ovarian reserve
or
• Whether conservative endometriotic surgery effect ovarian reserve.
• Independent of mechanical stretching owing to its size
,endometrioma has toxic effect on adjacent Ovarian cortical tissue.
• Levels of AMH significantly decreased in women with stages lll & lV
endometriosis.
17. • EARLY or PREMATURE Menopause
• 1. Detrimental effect of endometrioma on ovarian cortex.
• 2. Ovarian Surgery for Bilateral endometrioma influences age at
Menopause with increased risk of premature Ovarian insufficiency.
• 3. Treatment by TAH with B/L SO at an early age.
• 4. Ovarian preservation carries 6 fold risk of recurrent pain and 8 fold
risk of reoperation.
18. Recurrence of Endometriosis, Malignant
Transformation.
• Endometriosis lesions may recur with use of MHT in pts who had
Hysterectomy with B/L SO for pain relief at an early age.
• Prominent risk factor for recurrence among women with MHT is
peritoneal involvement more than 3 cm.
• Endometriosis is a benign proliferative condition but malignant
change can occur in 1% of cases .
• Endometriotic cells share common feature with malignant cells.
• Endometriotic tissue sensitive for reactivation or Malignant
Transformation if exposed to estrogen like uterine endometrium .
19. • Endometriosis may be metaplastic component of malignant
transformation.
• Endometriosis associated with 50% increase in risk of Epithelial
ovarian carcinoma.
• Most common malignancies associated with endometriosis are
Endometrioid and Clear cell Ovarian cancer.
• In Ovarian Endometriomas > 3cm. In diameter and in deeply
infiltrating disease a histological confirmation to exclude malignancy
is necessary.
21. • The first line of treatment is surgery and if needed followed by
aromatase inhibitors or Progesterones.
• WHY SURGERY ?
• 1. Diagnosis uncertainty.
• 2. Risk of associated malignancy.
• However recurrences are common after surgical treatment and 2nd
line drug treatment may be necessary.
22. • Presacral neurectomy or lower uterine nerve ablation do not have any
additional benefit. May cause chronic constipation and Bladder
dysfunction.
• PRIOR to ANY SURGERY for SUPPOSED RECURRENCES
• RULE OUT…
• 1. Irritable bowel syndrome
• 2. Interstitial Cystitis
• Myo fascial and vertebral pathologies.
23. Da Vinci Surgical System
• Being used for Diagnosis and treatment of Endometriosis.
• 3D vision offers advantage of improved depth perception and
accuracy in performance of Robotic Surgery.
• Before Da Vinci,Diagnostic laparoscopy to exclude upper abdomen
endometriotic lesions
• Disadvantages.
• 1. Unidirectional view
• 2. Loss of haptic feedback to identify fibrotic lesions.
25. • Aromatase enzyme catalyzes conversion of androstenedione and
testosterone to esterone and Estradiol.
• This enzyme found in adipocytes, ectopic endometriotic lesions in pts
with endometriosis.
26. • 3rd generation Aromatase Inhibitors Exemestane (Aromasin),
Letrozole (Femara) , Anastrazole (Arimidex) selectively block the
action of aromatase.
• Prolonged treatment effective in alleviating pain including urinary and
digestive symptoms.
27. Side effects
• 1. Hot flushes
• 2. Vaginal Dryness
• 3.Joint pains
• 4. Decreased Bone mass density
• Before prescribing AI , test for Osteoporosis risk factors and bone
mass density should be done.
28. Progestogens
• Widely used,
• Effective in treating endometriotic pain before Menopause.
• They act thru negative feedback mechanism on HPO axis inducing
anovulation and thru progesterone receptors - atrophy of
endometriotic lesion.
• Natural progesterone are preferred due to metabolic friendly profile .
• Continuous exposure to levonorgestrel exerts a local effect on
endometrium inducing atrophy.
29. Management of Menopausal Symptoms after
Endometriosis.
• Use of MHT in women with H/O endometriosis may be risk of disease
recurrence and pain symptoms
• Possibility of malignant transformation of residual endometriosis.
30. • Estrogen threshold hypothesis… By Barbieri..
• A concentration of estradiol which prevent Bone loss and may not
stimulate Endometrial growth.
• A concentration less than 20 pg/ml usually causes lesions to regress
and greater than 60 pg/ml supports lesion growth.
• Estradiol conc . Below 20pg/ml related with moderate to severe hot
flushes and bone loss .
31. • According to hypothesis estradiol concentration between 20pg to
45pg/ml may cause endometriotic lesion to regress and will reduce
pelvic pain and bone loss
32. Type of MHT
• Estrogen+Progesterone
• INDICATIONS…..
• 1. Extensive disease where surgery incomplete.
• 2. In obese patients with higher levels of exogenous Estrogen.
33. REGIME
• Continuous Combined preparations appear preferable to sequential
as symptoms of endometriosis fluctuate cyclically.
• HRT should be started immediately after surgery.
34. Management of De Novo lesions
• Appears after
• 1. Unopposed Estrogen therapy
• . 2. Obesity
Postmenopausal women with symptomatic endometriosis should be
managed surgically with removal of all visible endometriotic tissue
because of higher risk of recurrence and risk of malignancy.
• Medical therapy Can be used for....
• 1. Recurrence of pain
• 2. When surgery Contraindicated ,comorbidities or extensive
pelvic adhesions.
• 3. Advanced Age.
35. Tamoxifen and Post menopausal
Endometriosis
• Tamoxifen A SERM used in postmenopausal women with Breast
Cancer
• Antiestrogenic effect on breast.
• Promotes endometriosis
• May be some relation with ovarian endometriosis carcinoma.
