Endometriosis in a postmenopausal woman without previous hormonal therapy: a case report
© Manero et al; licensee BioMed Central Ltd. 2009
Received: 17 December 2008
Accepted: 18 November 2009
Published: 18 November 2009
The prevalence of pelvic endometriosis is high, affecting approximately 6% to 10% of women of reproductive age. Although endometriosis has been associated with the occurrence of menstrual cycles, it can affect between 2% to 5% of postmenopausal women.
We present a case of ovarian endometriosis in a 62-year-old Spanish Caucasian woman with no previous use of hormonal therapy and no history of endometriosis or infertility.
Although the reported situation is rare, it is important to be aware of endometriosis after the menopause: post-menopausal endometriosis confers a risk of recurrence and malignant transformation.
Endometriosis is a common, benign, estrogen-dependent, chronic gynecological disorder commonly associated with pelvic pain and infertility. The prevalence of pelvic endometriosis is high, affecting approximately 6% to 10% of women of reproductive age . Although endometriosis has been associated with the occurrence of menstrual cycles, it can affect between 2% to 5% of postmenopausal women , and generally occurs as a side effect of hormone use [3, 4]. In these cases, a differential diagnosis to exclude malignancies is critical. However, endometriosis can also occur in postmenopausal women not receiving exogenous hormones, indicating the complex pathogenesis of endometriosis. In clinical practice, the discrimination between endometriosis and cancer is further complicated by the fact that some of the risk factors for endometriosis and ovarian malignancy are similar: a low rate of parity, infertility, late childbearing age, and a short duration of oral contraceptive use . Although there are some reports of successful results with treatments such as aromatase inhibitors , we think that surgery should be the first step in the management of postmenopausal ovarian endometriosis.
We present a case of ovarian endometriosis in a postmenopausal woman with no previous hormonal therapy (HT) use and no history of endometriosis or infertility.
Postmenopausal endometriosis was first reported in 1950. Although a rare disease, it should be considered in postmenopausal and women who have undergone hysterectomy with classical symptoms of endometriosis, mostly pain.
In the presence of adnexal masses in postmenopausal women, the gynecologist must always consider the possibility of a malignant ovarian tumor. In spite of being an uncommon disease after menopause, endometriosis, which is known to be estrogen-dependent, is been included in the list of possible differential diagnoses when dealing with postmenopausal women. In these cases, the theoretical celomic metaplasia etiopathogenic mechanism [7, 8] could explain the occurrence of postmenopausal ovarian endometriotic lesions. Another possible explanation is endometrial stem cells from vascular endometrial cell transportation, which occurs primarily when endometriotic lesions appear in areas that do not have contact with menstrual retrograde flow [9, 10].
These investigations suggest that some interleukins (interleukin (IL)1, IL2, IL6, IL8, IL10) and other inflammatory mediators (tumor necrosis factor alfa, interferon gamma, monocyte chemotactic protein-1) could play a main role in the endometriosis pathophysiology, allowing ectopic endometrial cells to implant and grow or triggering a celomic metaplasia etiopathogenic mechanism. We postulate that some postmenopausal women could have a relative immunosuppression status that allows the lesions to establish and progress .
Although the condition is rare, it is important to be aware of endometriosis after menopause. Postmenopausal endometriosis confers a risk of recurrence and malignant transformation. Some endometriosis lesions may predispose to clear cell and endometrioid ovarian cancers. Ovarian endometriomas that are 9 cm or greater in diameter are a strong predictor for development of ovarian cancer in postmenopausal women of 45 years of age or older .
Although conclusive evidence is lacking, the risk of malignant transformation appears to be lower with combined HT compared with estrogen-only therapy. Thus, hormone replacement therapy should generally be reserved for patients with severe climacteric complaints, and if indicated, combined therapy should be used .
Although the reported situation is rare, it is important to be aware of endometriosis after the menopause: post-menopausal endometriosis confers a risk of recurrence and malignant transformation
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
We thank Dr Guillermo López García for his valuable suggestions.
- Dabrosin C, Gyorffy S, Margetts P, Ross C, Gauldie J: Therapeutic effect of angiostatin gene transfer in a murine model of endometriosis. Am J Pathol. 2002, 161: 909-918.PubMed CentralView ArticlePubMed
- Punnonen R, Klemi PJ, Nikkanen V: Postmenopausal endometriosis. Eur J Obstet Gynecol Reprod Biol. 1980, 11: 195-200. 10.1016/0028-2243(80)90069-6.View ArticlePubMed
- Goumenou AG, Chow C, Taylor A, Magos A: Endometriosis arising during oestrogen and testosterone treatment 17 years after abdominal hysterectomy: a case report. Maturitas. 2003, 46: 239-241. 10.1016/S0378-5122(03)00081-1.View ArticlePubMed
- Sesti F, Vettraino G, Pietropolli A, Marziali M, Piccione E: Vesical and vaginal endometriosis in postmenopause following estrogen replacement therapy. Eur J Obstet Gynecol Reprod Biol. 2005, 118: 265-266. 10.1016/j.ejogrb.2004.04.028.View ArticlePubMed
- Ness RB: Endometriosis and ovarian cancer: thoughts on shared pathophysiology. Am J Obstet Gynecol. 2003, 189: 280-294. 10.1067/mob.2003.408.View ArticlePubMed
- Takayama K, Zeitoun K, Gunby RT, Sasano H, Carr BR, Bulun SE: Treatment of severe postmenopausal endometriosis with an aromatase inhibitor. Fertil Steril. 1998, 69: 709-713. 10.1016/S0015-0282(98)00022-3.View ArticlePubMed
- Magtibay PM, Heppell J, Leslie KO: Endometriosis-associated invasive adenocarcinoma involving the rectum in a postmenopausal female. Dis Colon Rectum. 2001, 44: 530-533. 10.1007/BF02234612.View Article
- Oral E, Ilvan S, Tustas E, Korbeyli B, Bese T, Demirkiran F, Arvas M, Kosebay D: Prevalence of endometriosis in malignant epithelial ovary tumours. Eur J Obstet Gynecol Reprod Biol. 2003, 109: 97-101. 10.1016/S0301-2115(03)00047-2.View ArticlePubMed
- Bese T, Simsek Y, Bese N, Ilvan S, Arvas M: Extensive pelvic endometriosis with malignant change in tamoxifen-treated postmenopausal women. Int J Gynecol Cancer. 2003, 13: 376-380. 10.1046/j.1525-1438.2003.13188.x.View ArticlePubMed
- Jelovsek JE, Winans C, Brainard J, Falcone T: Endometriosis of the liver containing mullerian adenosarcoma: case report. Am J Obstet Gynecol. 2004, 191: 1725-1727. 10.1016/j.ajog.2004.05.031.View ArticlePubMed
- González Ramos P, Royo Manero P, Pastor OC, Calleja Aguayo E, De Martino A, Rodino J, Bejarano Lasunción P, Pecondón A, Vicente B, Gracia Romero J, Ortega J, García Manero M, Alcázar Zambrano JL, González de Agüero R, Fabre González E: GREMIO Collaboration Group. University of Zaragoza (Spain). PGR-1 Hot-Dog: a new rat model for the study of the experimentally-induced endometriosis in rats. Proceedings of the 13th World Congress on Human Reproduction: 5-8 March 2009; Venice (Italy). 2009, 89 (161):
- Kobayashi H, Sumimoto K, Kitanaka T, Yamada Y, Sado T, Sakata M, Yoshida S, Kawaguchi R, Kanayama S, Shigetomi H, Haruta S, Tsuji Y, Ueda S, Terao T: Ovarian endometrioma--risks factors of ovarian cancer development. Eur J Obstet Gynecol Reprod Biol. 2008, 138: 187-193. 10.1016/j.ejogrb.2007.06.017.View ArticlePubMed
- Oxholm D, Knudsen UB, Kryger-Baggesen N, Ravn P: Postmenopausal endometriosis. Acta Obstet Gynecol Scand. 2007, 4: 1-7.
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.