Postmenopausal endometriosis

Postmenopausal endometriosis: a challenging condition beyond menopause

IMPORTANCE AND OBJECTIVE

Postmenopausal endometriosis is a complex condition that challenges the conventional belief that endometriosis resolves with menopause. Despite the cessation of menstruation, a subset of women continues to experience or develop endometriosis-related symptoms during the postmenopausal period. Thus, this review aimed to shed light on postmenopausal endometriosis, exploring its clinical features, diagnostic considerations, management approaches, and the potential impact on women's health.

METHODS

PubMed/Medline, Scopus, and Web of Science databases were used for the research, with only articles in English language, using the following terms: "postmenopausal endometriosis," "menopause," "management," "treatment," and "quality of life," from inception to 2023.

DISCUSSION AND CONCLUSION

The clinical features of postmenopausal endometriosis include persistent or recurrent pelvic pain, dyspareunia, bowel, or urinary symptoms and, occasionally, abnormal vaginal bleeding. The absence of menstrual cycles presents a diagnostic challenge, as the traditional diagnostic criteria for endometriosis rely on menstrual patterns. Visual cues may be less evident, and the symptoms often overlap with other gynecological conditions, necessitating a thorough evaluation to differentiate postmenopausal endometriosis from other potential causes. Management approaches for postmenopausal endometriosis encompass surgical intervention, hormonal therapies, pain management, and individualized care. Postmenopausal endometriosis significantly impacts the quality of life, sexual health, and long-term well-being of women. Understanding the clinical features, diagnostic challenges, and management approaches of postmenopausal endometriosis is crucial for healthcare professionals to provide effective care and to improve the quality of life of women affected by this condition.

An Unexpected Discovery: Postmenopausal Pyloric Endometriosis

Endometriosis is a benign, estrogen-dependent condition, usually occurring in menstruating and, rarely, in postmenopausal women, in which endometrial glands and stroma grow ectopically outside the uterus. Most often, ectopic endometrial tissue is found within the pelvis and nearby structures. However, endometrial tissue within the upper gastrointestinal tract is very rare and can be a source of bleeding and abdominal pain. Here, we report a case of a 71-year-old postmenopausal woman with hematochezia and diffuse abdominal pain, who was found to have pyloric endometriosis, the pathogenesis of which we will briefly explore.

Endometriosis in Menopausal Women-A New Age Is Coming? Literature Review

Endometriosis is a chronic inflammatory disease, characterized by the presence of ectopic endometrial tissue, that leads to dysmenorrhea, painful intercourse and infertility. The shift in paradigm from the previous belief that endometriosis exclusively impacts women of reproductive age has brought attention to the condition in both premenarchal and postmenopausal women. Currently, 2-4% of postmenopausal women have endometriosis. Many women experience menopausal symptoms during the peri- and postmenopausal periods and require extensive investigations and monitoring in order to avoid the recurrence of endometriosis symptoms or the risk of malignant transformation when treatment with menopausal hormones is elected. Our goal was to compile and present a clear and concise overview of the existing literature on postmenopausal endometriosis, offering an up-to-date and precise summary of the available information.

New insights about endometriosis-associated ovarian cancer: pathogenesis, risk factors, prediction and diagnosis and treatment

Previous studies have shown that the risk of malignant transformation of endometriosis in premenopausal women is approximately 1%, significantly impacting the overall well-being and quality of life of affected women. Presently, the diagnostic gold standard for endometriosis-associated ovarian cancer (EAOC) continues to be invasive laparoscopy followed by histological examination. However, the application of this technique is limited due to its high cost, highlighting the importance of identifying a non-invasive diagnostic approach. Therefore, there is a critical need to explore non-invasive diagnostic methods to improve diagnostic precision and optimize clinical outcomes for patients. This review presents a comprehensive survey of the current progress in comprehending the pathogenesis of malignant transformation in endometriosis. Furthermore, it examines the most recent research discoveries concerning the diagnosis of EAOC and emphasizes potential targets for therapeutic intervention. The ultimate objective is to improve prevention, early detection, precise diagnosis, and treatment approaches, thereby optimizing the clinical outcomes for patients.

Endometrial Cyst Presenting as a Vague Abdominal Lump in a Postmenopausal Woman

A postmenopausal woman presented with a predominantly right-sided abdominal lump, insidious in onset and not associated with any aggravating or relieving factors. Physical examination revealed a soft cystic mass extending from the right hypochondrium to the right iliac fossa region crossing the midline. Ultrasonography of the abdomen and pelvis showed a large cystic anechoic area noted in the abdomen extending from the epigastric region to the pelvis. Contrast-enhanced CT of the abdomen and pelvis showed a large non-enhancing cystic lesion in the pelvis suggesting the possibility of a right ovarian cyst or mesenteric cyst. Laparotomy was performed and the excised specimen was sent for histopathological analysis, which confirmed it to be an endometrial cyst.

Endometriosis arising in a cesarean section scar: A case report

Introduction and importance

Scar endometriosis is an uncommon variant of extra pelvic endometriosis, which develops at the scar site of previous abdominopelvic surgery and is seen in women during their reproductive period.

Case presentation

We report a 38-year-old female who presented with a nine-months history of a painful ulcerative mass that developed on a cesarean section scar. The mass was removed by a wide excision and confirmed by histology to be endometriosis.

Clinical discussion

Wide surgical resection of ectopic endometriosis is the treatment of choice. It is usually curative and ensures the confirmation of the diagnosis.

Conclusion

Cesarean section scar endometriosis can undergo malignant transformation. This case highlights the need for early detection and treatment.

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Cesarean section scar endometriosis is an uncommon variant of extra pelvic endometriosis

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Wide surgical resection of ectopic endometriosis is the treatment of choice.

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Scar endometriosis can undergo malignant transformation; therefore, early detection and treatment is of a dire need

Age‐dependent phenotypes of ovarian endometriomas

Purpose

To analyze the characteristics of the ovarian endometrioma (OE) across the life span of a woman. In the past, the OE has traditionally been viewed as a single, monolithic disease. Today, there are emerging data indicating that OE phenotypes differ according to the age of the woman.

Method

A narrative review of original articles on OE indexed by PubMed.

Results

When appearing in infancy and early adolescence, OE may be the consequence of endometrial cells retrogradely shed with neonatal uterine bleeding. The post‐menarcheal variant, manifesting itself during full adolescence, is singularly frequent in the presence of vaginal or uterine outflow obstructive anomalies. The typical and most frequent adult phenotype is characterized by increasing fibrosis and a tendency to progress; its mere presence exerts a detrimental effect on the surrounding healthy ovarian tissue. In postmenopause, an old lesion may be reactivated in the presence of exogenous or endogenous estrogens, or even be produced ex novo; rarely, it can spread to a variety of organs and structures and even degenerate causing malignancies.

Conclusions

Given the existence of these variants, it is important to agree on management guidelines that take into consideration these different phenotypes.

Traditionally, ovarian endometriomas are considered rightfully as one subtype of endometriosis that is different from other subtypes. Beyond that, it is considered as a monolithic disease entity. In this review, we synthesized published data and argue that this subtype actually has age‐dependent phenotypes, and as such, management should be ideally tailored to achieve the best results.

Updates of Pathogenesis, Diagnostic and Therapeutic Perspectives for Ovarian Clear Cell Carcinoma

Ovarian clear cell carcinoma (OCCC) is a special pathological type of epithelial ovarian carcinoma (EOC) and has a high prevalence in Asia without specific molecular subtype classification. Endometriosis is a recognized precancerous lesion that carries 3-fold increased risk of OCCC. Ovarian endometrioid carcinoma, which also originates from endometriosis, shares several features with OCCC, including platinum resistance and younger age at diagnosis. Patients with OCCC have about a 2.5 to 4 times greater risk of having a venous thromboembolism (VTE) compared with other EOC, and OCCC tends to metastasize through lymphatic vesicular and peritoneal spread as opposed to hematogenous metastasis. There is only mild elevation of the conventional biomarker CA125. Staging surgery or optimal cytoreduction combined with chemotherapy is a common therapeutic strategy for OCCC. However, platinum resistance commonly portends a poor prognosis, so novel treatments are urgently needed. Targeted therapy and immunotherapy are currently being studied, including PARP, EZH2, and ATR inhibitors combined with the synthetic lethality of ARID1A-dificiency, and MAPK/PI3K/HER2, VEGF/bFGF/PDGF, HNF1β, and PD-1/PD-L1 inhibitors. Advanced stage, suboptimal cytoreduction, platinum resistance, lymph node metastasis, and VTE are major prognostic predictors for OCCC. We focus on update pathogenesis, diagnostic methods and therapeutic approaches to provide future directions for clinical diagnosis and treatment of OCCC.

Endometriosis in Menopause-Renewed Attention on a Controversial Disease

Endometriosis, an estrogen-dependent inflammatory disease characterized by the ectopic presence of endometrial tissue, has been the topic of renewed research and debate in recent years. The paradigm shift from the belief that endometriosis only affects women of reproductive age has drawn attention to endometriosis in both premenarchal and postmenopausal patients. There is still scarce information in literature regarding postmenopausal endometriosis, the mostly studied and reported being the prevalence in postmenopausal women. Yet, other important issues also need to be addressed concerning diagnosis, pathophysiology, and management. We aimed at summarizing the currently available data in literature in order to provide a concise and precise update regarding information available on postmenopausal endometriosis.

Epidemiological aspects of the outcomes from the treatment of endometriosis: Experience from two different geographical areas

The purpose of the present study was two-fold: First to review the epidemiological aspects of the experience on the surgical outcomes via laparotomy or laparoscopy, as regards endometriosis from two different academic institutions and, second, to illustrate potential differences in two different geographical areas, New Haven (US) and Greece. This retrospective study included 1,200 patients (15–80 years of age) treated via laparotomy or laparoscopy, at two different institutions, for endometriosis, between 1990 and 2017. Data were collected and analyzed from medical and pathological reports. The statistical methods used included the Student's t-test and χ² test, as well as the Mann-Whitney U test. A total of 600 women from Yale University and 600 women from Greece participated in this study. Endometrioma was confirmed in 359 (29.9%) cases. Women were compatible in terms of the site of endometriomas. Left-sided cysts were observed (P<0.001) significantly more often compared with right-sided cysts in both groups. The two groups of patients had similar rates of endometriosis stages. A statistically significant positive association (P<0.001) was found for the co-existence of benign gynecological tumors (apart from endometrioma), endometriosis-associated ovarian cancer and for post-menopausal endometriosis in women with endometriosis from Greece. Moreover, similar results were observed as regards endometriosis following in utero exposure to diethylstilbestrol (DES), non-Hodgkin's lymphoma, endometriosis-associated Lyme disease, human immuno-deficiency virus (HIV), melanoma and endometriosis in adolescents, between the two groups. To conclude, the two populations exhibited similar results as regards the surgical outcomes of endometriosis laparoscopic or open surgery. Endometriosis represents a multifactorial entity that depends on complex interactions of hormonal, genetic, immunological and environmental factors. Gynecologists should be aware that there is an association between endometriosis and cancerous diseases. It is thus suggested that the presence of comorbidities in women with endometriosis.

Postmenopausal endometriosis, where are we now?

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.

Endometriotic Mass After Hysterectomy in a 61 Year Old Post-menopausal Woman: A Case Report and Update

Endometriosis is a common, hormone-dependent gynecologic disease. Undiagnosed in large proportion of women, managing therapies depend on the impact of quality of life and includes hormonal treatment and pelvic surgery. Less likely endometriosis can occur in post-menopausal women. Malignant transformation of endometriosis is a rare but well-described process, most of time occurring in the ovary, and justifies the practitioner not to underestimate this pathology. We present a case of a 61 year old woman with a symptomatic endometriotic pelvic mass, status post hysterectomy, with no history of endometriosis diagnosed beforehand.

Keeping an Eye on Perimenopausal and Postmenopausal Endometriosis

Introduction: We aimed to describe and review the epidemiological aspect of the disease pattern of a series of perimenopausal and postmenopausal women with a histology confirmation of endometriosis. Material and Methods: We retrospectively examined the clinical records of 184 perimenopausal and 46 postmenopausal women with endometriosis. Data were collected and analyzed from 1100 patients' charts with confirmed endometriosis and involved cases from two different geographical areas, New Haven (US) and Greece. The statistical methods included ײ and the Mann-Whitney U test. In the perimenopausal group (age 45⁻54 years), there were 184 patients (16.7%) and the postmenopausal group (55⁻80 years) had 46 (4.2%). The average age of diagnosis was (49 ± 2.3) and (61.2 ± 5.1), respectively (p < 0.01). Results: Advanced endometriosis was more aggressive in the perimenopausal group (p < 0.05); in the same group, we observed a higher left-sided predisposition of endometriosis in comparison with the right side (p < 0.01). Endometrioma was the most common gynecological condition among patients with perimenopausal endometriosis in relation to the postmenopausal group (p < 0.001). Additionally, we found uterine leiomyomata more prominent in the perimenopausal group (p < 0.05). In contrast, adenomyosis was found higher in postmenopausal patients (p < 0.05); further, 24 cases with dry eye we observed. Conclusions: Postmenopausal endometriosis is an important underestimated condition. Although the reported situation is not common, various clinicopathological characteristics were observed in both groups. Clinicians should be aware that there is a correlation between endometriosis and endometriosis-associated ovarian cancer in perimenopausal and postmenopausal age.

Symptomatic endometriosis developing several years after menopause in the absence of increased circulating estrogen concentrations: a systematic review and seven case reports

Background

To review women with symptomatic and clinically progressive endometriosis after menopause in the absence of estrogen intake or excessive systemic endogenous production.

Design

Seven case reports and a systematic review of the literature from 1995 till February 2018.

Results

Only 7 case reports from the authors and 29 cases from the literature described women with either cystic ovarian or deep endometriosis. Severity, symptoms, and localization are highly variable. No case report describes symptomatic superficial typical lesions. In 22 of 36 women (61%), symptoms started more than 10 years after menopause.

Conclusions

Symptomatic and clinically progressive endometriosis after menopause in the absence of increased systemic estrogen concentrations or exogenous estrogen intake starts more than 10 years after menopause in the majority of women. This observation suggests that a genetic and/or epigenetic incident caused estrogen-independent progression, increased sensitivity to estrogens or increased local production of estrogens. This observation is important for understanding the pathophysiology of endometriosis, for the management of postmenopausal endometriosis, and for individualization of medical therapy of endometriosis since estrogen-independent endometriosis growth probably also occurs before menopause.

Clinicopathologic characteristics of ovarian clear cell carcinoma in the background of endometrioma: a surveillance strategy for an early detection of malignant transformation in patients with asymptomatic endometrioma

Objective

This study aimed to analyze the clinical features of clear cell carcinoma in relation to endometriosis and to determine an appropriate surveillance strategy for the early detection of malignant transformation of endometrioma in asymptomatic patients.

Methods

We retrospectively reviewed the clinicopathologic data of 50 patients with ovarian clear cell carcinoma. Clinicopathologic characteristics, treatment outcomes, and the association between endometriosis and the risk of malignant transformation were analyzed.

Results

Ten (20%) patients had been diagnosed with endometrioma before the diagnosis of clear cell carcinoma. The median period from the diagnosis of endometrioma to clear cell carcinoma diagnosis was 50 months (range, 12–213 months). After complete staging surgery, histological confirmation of endometriosis was possible in 35 (70%) patients. Of the 50 patients, 39 (78%) had not undergone any gynecologic surveillance until the onset of symptoms, at which time many of them presented with a rapidly growing pelvic mass (median 10 cm, range 4.6–25 cm). With the exception of 2 patients, all cancer diagnoses were made when the patients were in their late thirties, and median tumor size was found to increase along with age. Asymptomatic patients (n=11) who had regular gynecologic examinations were found to have a relatively smaller tumor size, lesser extent of tumor spread, and lower recurrence rate (P=0.011, 0.283, and 0.064, respectively). The presence of endometriosis was not related to the prognosis.

Conclusion

Considering the duration of malignant transformation and the timing of cancer diagnosis, active surveillance might be considered from the age of the mid-thirties, with at least a 1-year interval, in patients with asymptomatic endometrioma.

The management of menopause in women with a history of endometriosis: a systematic review

BACKGROUND

Endometriosis is typically regarded as a premenopausal disease, resolving after natural or iatrogenic menopause due to declining oestrogen levels. Nonetheless, case reports over the years have highlighted the incidence of recurrent postmenopausal endometriosis. It is now clear that both recurrence and malignant transformation of endometriotic foci can occur in the postmenopausal period. Postmenopausal women are commonly treated with hormone replacement therapy (HRT) to treat climacteric symptoms and prevent bone loss; however, HRT may reactivate endometriosis and stimulate malignant transformation in women with a history of endometriosis. Given the uncertain risks of initiating HRT, it is difficult to determine the best menopausal management for this group of women.

OBJECTIVE AND RATIONAL

The aim of this study was to systematically review the existing literature on management of menopausal symptoms in women with a history of endometriosis. We also aimed to evaluate the published literature on the risks associated with HRT in these women, and details regarding optimal formulations and timing (i.e. initiation and duration) of HRT.

SEARCH METHODS

Four electronic databases (MEDLINE via OVID, Embase via OVID, PsycINFO via OVID and CINAHL via EbscoHost) were searched from database inception until June 2016, using a combination of relevant controlled vocabulary terms and free-text terms related to 'menopause' and 'endometriosis'. Inclusion criteria were: menopausal women with a history of endometriosis and menopausal treatment including HRT or other preparations. Case reports/series, observational studies and clinical trials were included. Narrative review articles, organizational guidelines and conference abstracts were excluded, as were studies that did not report on any form of menopausal management. Articles were assessed for risk of bias and quality using GRADE criteria.

OUTCOMES

We present a synthesis of the existing case reports of endometriosis recurrence or malignant transformation in women undergoing treatment for menopausal symptoms. We highlight common presenting symptoms, potential risk factors and outcomes amongst the studies. Sparse high-quality evidence was identified, with few observational studies and only two randomized controlled trials. Given this paucity of data, no definitive conclusions can be drawn concerning risk.

WIDER IMPLICATIONS

Due to the lack of high-quality studies, it remains unclear how to advise women with a history of endometriosis regarding the management of menopausal symptoms. The absolute risk of disease recurrence and malignant transformation cannot be quantified, and the impact of HRT use on these outcomes is not known. Multicentre randomized trials or large observational studies are urgently needed to inform clinicians and patients alike.

Predictive factors of ovarian carcinoma for women with ovarian endometrioma aged 45 years and older in China

BACKGROUND

To explore the risk factors of endometriosis-associated ovarian cancer (EAOC) in women with ovarian endometriosis (OEM) aged 45 years and above in China.

METHODS

This study reviewed the medical records of 1038 women in total who were aged 45 years and above, surgical-pathologically diagnosed with ovarian endometriosis, and were treated at Peking Union Medical College Hospital between December 1996 and December 2016. Histology evaluation was used to determine whether the ovarian endometriosis specimen was with (n = 30) or without (n = 1008) ovarian cancer.

RESULTS

2.9% (30/1038) of women with the surgical-pathological diagnosis of ovarian endometriosis were found to have EAOC. Those patients with EAOC were prone to be in the postmenopausal status at the time of the diagnosis (OR 5.50, 95%CI 2.54-11.90, P < .001) and larger size of tumor (≥8 cm, OR 7.19, 95% CI 3.34-15.50, P < .001), and higher prevalence of coexisting with endometrial disorders (OR 4.11, 95%CI 1.73-9.73, P = .003). This study showed that patients of an older age when diagnosed with OEM, were at a higher risk of developing EAOC, respectively measuring of 1.7% (13/751) at 45-49 years, 5.6% (12/215) at 50-54 years, and 10.0%(5/50) at 55-59 years (P < 0.001).

CONCLUSIONS

This study showed that for women aged 45 years and above who were diagnosed with OEM, the independent risk factors of EAOC were menopausal status, tumor size of 8 cm or greater in diameter, and coexisting endometrial disorders. Therefore, intensive follow-ups or active interventions should be considered for them.

The use of Hormone Therapy after Surgery for Endometriosis: An Analysis

Introduction

Estrogen dependence is considered central to the development and progression of endometriosis, which is often viewed as a disease of the premenopausal years, normally regressing after menopause. However, there have been several reports of postmenopausal endometriosis occurring with and without the use of hormone therapy (HT).

Objective

This review aimed to answer the question of whether it is prudent to offer HT for women with a past history of surgical endometriosis. What are the risks? What type of HT should be given?

Methods

A review of the medical literature available in Pubmed, EMBASE, Google scholar, Lilacs, Medline and Cochrane Library databases was performed by selecting articles published in the last ten years, written in any language. The keywords used were endometriosis, menopause, and hormone therapy. In all, 36 articles were found from 2006 to 2016, and their potential relevance to this review was examined. We found 20 literature reviews, 2 retrospective studies, 2 randomized controlled trials and 12 case reports.

Results

There is some risk of endometriosis recurrence after the menopause in patients who receive HT; particularly with estrogen-only therapy.

Conclusions

The existing literature is inadequate to firmly answer our questions. However it is clear that some risk of recurrence exists. Nevertheless, it is suggested that it is reasonable to prescribe HT to women with a history of surgical endometriosis. Recurrences may occur even in the absence of using HT. It is suggested that in women with severe disease the use of estrogen plus progestogen is safer than estrogen alone. Malignant transformation may occur 1% of the time and may be of greater concern with using estrogen alone, warranting close surveillance in all women.

Unusual Case of Postmenopausal Diffuse Endometriosis Mimicking Metastastic Ovarian Malignancy

Endometriosis is a common gynecologic condition of the premenopausal years. However, postmenopausal endometriosis is rare (2.2%) and thought to be related to high level of circulating estrogen, especially in hormonal replacement therapy. We present a case of a 69-year-old postmenopausal woman, previously healthy and on no regular medication, with diffuse peritoneal endometriosis and bilateral ovarian endometrioma mimicking metastatic ovarian carcinoma on FDG PET/CT. Both ovarian endometrioma had low-grade activity, but more strikingly, there was diffuse FDG-avid peritoneal dissemination and gross ascites. Endometriosis should not be totally disregarded as a differential diagnosis even at postmenopausal status.

Effects of cisplatin and letrozole on surgically induced endometriosis and comparison of the two medications in a rat model

This study was to investigate the effects of cisplatin (CDDP) and letrozole on surgically induced endometriosis and comparison of the two drugs in a rat model. Endometriosis was surgically induced by autologous transplantation of endometrial pieces. Thirty model rats were divided into three groups, randomly. Group 1 (n=10) served as control and received no medication. Group 2 (n=10) received 0.2mg/kg/day of oral letrozole. Group 3 (n=10) received 35mg/m(2) CDDP via peritoneal perfusion every four days. All the rats were treated for 24days. The growth and histologic score of the implants were evaluated. The proliferation- and angiogenesis-associated proteins were assessed using immunohistochemistry and western blotting. The serum sex hormones were assayed using ELISA. After the medication, the growth and histologic score of the implants were significantly lower in the 2 and 3 groups than in the control group. The protein expressions of vascular endothelial growth factor (VEGF), aromatase P450 (P450arom), transforming growth factor-beta (TGF-β), and matrix metalloproteinase (MMP)-2, were significantly lower in groups 2 and 3 than in the control group. Further, the P450arom level was lower in the letrozole group than in the CDDP group. The TGF-β and MMP-2 levels were lower in the CDDP group than in the letrozole group. Serum T level was significantly higher in the letrozole group, and serum E2 level was lower in the letrozole group. In conclusion, cisplatin and letrozole caused similar regression of the implants in the endometriosis model rats. But their effects on the proliferation- and angiogenesis-associated protein expressions and the serum sex hormone levels were different. Cisplatin and letrozole might cause the effects in the endometriotic foci through different mechanism.

Expect the unexpected: Endometriosis mimicking a rectal carcinoma in a post-menopausal lady

Altered bowels habits along with rectal mass in an elderly would point toward a rectal cancer. We report an unusual case of a post-menopausal lady who presented with these complaints. We had difficulties in establishing a pre-operative diagnosis. With a tentative diagnosis of a rectal cancer/gastrointestinal stromal tumor, she underwent a laparoscopic anterior resection. On histopathology, this turned out to be endometriosis. Bowel endometriosis is an uncommon occurrence. That it occurred in a post-menopausal lady was a very unusual finding. We discuss the case, its management, and the relevant literature.

Endometriosis and cancer

Endometriosis is manifested by the presence of both endometrial glandular and stromal cells outside the uterine cavity. It is characterized by ectopic implantation of endometrial cells with elevated proliferation and migration. Endometriosis is the leading cause of morbidity among premenopausal women and the complex pathogenesis of this disease remains controversial despite extensive research. This rather complex disease has a significant impact on quality of life of many women as none of the current treatments represent a cure. Based on the current knowledge, one can conclude that the histological and genetic alterations in endometriosis might explain why and how endometriosis can change into several types of cancer. However, the exact mechanisms of this conversion are still not fully established.

Evidence for the Relationship Between Endometriosis and Epithelial Ovarian Cancer

Endometriosis may be a precursor lesion for some epithelial ovarian cancers (EOCs), especially those of clear cell and endometrioid histologies. The causality of this relationship remains controversial and in need of further investigation because the high prevalence of endometriosis and high mortality of EOC carry significant public health implications if the association is real. Endometriosis-associated ovarian cancer (EAOC) often presents at an earlier stage and with lower-grade lesions than non-EAOC. After surgical resection, these patients also tend to have less residual disease than do patients with non-EAOC. Survival has been reported to be better for women with EAOC. The tumor suppression gene, ARID1A, is frequently disrupted in EAOC. The ARID1A mutation has been reported in preneoplastic lesions and may be an early marker in the transformation of endometriosis into cancer. The current evidence in respect to critical molecular pathways underscores the need to investigate possible role of targeted therapies in the treatment of EAOC.

Tamoxifen-associated polypoid endometriosis mimicking an ovarian neoplasm

Tamoxifen has been widely used for adjuvant treatment of breast cancer, but several gynecological side effects have been noted, including endometrial hyperplasia, polyp and carcinoma. Polypoid endometriosis is one of the extremely rare benign complications associated with tamoxifen therapy. A 66-year-old postmenopausal woman, who had received left partial mastectomy due to breast cancer (about 4 years ago) and was taking tamoxifen treatment, had an ovarian cyst on ultrasonography. Pelvic magnetic resonance imaging suggested tamoxifen-associated endometrial and ovarian changes, especially a 4.1×3.4-cm-sized, well-defined, multicystic mass in the right ovary. She received hysterectomy with bilateral salpingo-oophorectomy. Microscopically, the right paratubal mass showed endometrial glands and stroma, and immunohistochemical staining for CD10 confirmed the endometrial nature of the stroma. Three cases of polypoid endometriosis have been reported in the Korean literature, but in none of the cases, polypoid endometriosis was associated with tamoxifen use. Herein, we report the first case of polypoid endometriosis associated with tamoxifen treatment in Korea.

Endometriosis and ovarian cancer

Endometriosis is the leading cause of morbidity among premenopausal women and the complex pathogenesis of this disease remains controversial despite extensive research. This disease represents one of the most common gynecological problems. It is generally believed that this disease is due primarily to retrograde menstruation or transplantation of shed endometrium. Based on overwhelming data, ovarian endometrioma is considered a neoplastic process, since most endometriosis-associated ovarian carcinoma occur in the presence of atypical ovarian endometriosis. A study comparing patients with typical epithelial ovarian cancer with endometriosis-associated ovarian cancer demonstrated that the patients with the latter disease strongly differ in both biological and histological characteristics. The prevelance of this disease is not completely established, but approximately 15 percent of women suffer from this disease. In addition, we know about the possible links between endometriosis and cancer for almost 100 years. Despite clear evidence revealing that endometriosis increases ovarian cancer risks, it is possible that it may not affect disease progression after the appearance of ovarian cancer. However, despite clear evidence revealing that endometriosis increases ovarian cancer risk, our knowledge of the risk factors is far from established. In our review, we focused on the most recent approaches including possible biomarkers and genetic approaches.

Predictive factors for the presence of malignant transformation of pelvic endometriosis

OBJECTIVES

To determine predictive factors for the presence of malignant transformation in ovarian endometriotic cysts.

STUDY DESIGN

This was an IRB approved, case control study analyzing patient data from 2004 to 2013. Pathology database records were searched to identify patients with benign endometrioma and ovarian carcinoma arising in the background of endometriosis. Inclusion criteria required each patient to have a preoperative diagnosis of adnexal mass and no other findings concerning for malignancy. Patient clinical records were queried for preoperative symptoms, serum CA125 levels and radiologic findings. Pathologic data were collected including histology, tumor grade and stage.

RESULTS

A total of 138 patients met inclusion criteria; 42 women with ovarian cancer arising in the background of endometriosis and 96 women with benign endometrioma. Women diagnosed with ovarian cancer were significantly older than women with endometriosis (53.6 vs. 39.2 years). There was no difference in presence of symptoms between the two groups. Women with malignant tumors were found to have significantly larger cysts (14 cm vs. 7.5 cm; p<0.0001) that were more often multilocular (45.7% vs. 12.2%; p<0.0001), and contained solid components (77.1% vs. 14.5%; p<0.0001). Among patients that were observed prior to surgery there was a significant difference in the change in size of the mass over time with 4.2 cm increase for cases vs. 1.0 cm increase for controls (p=0.02). Multiple logistic regression analysis indicated that for every 5 years increase in age there was an adjusted OR of 2.17 (p=0.003). An age of 49 years or greater had an 80.6% sensitivity (95% CI: 62.5-92.5%) and an 82.9% specificity (95% CI: 67.9-92.8%) for malignancy, and solid component on imaging had an adjusted OR of 23.7 (p<0.0001). Serum CA125 levels tended to be higher in patients with malignant tumors but did not reach statistical significance with a mean of 204.9 vs. 66.9 (p=0.1).

CONCLUSIONS

Significant predictors for malignant transformation of endometriosis include cyst characteristics and age. Women above the age of 49 with multilocular cysts and solid components are at high risk for malignant transformation of endometriosis. Serum CA125 level is not a significant predictor of malignant transformation.

RUNX3 is inactivated by promoter hypermethylation in malignant transformation of ovarian endometriosis

The aim of the present study was to investigate the role of epigenetic inactivation of the runt-related transcription factor 3 gene (RUNX3) in the malignant transformation of ovarian endometriosis. Samples obtained by microdissection and scraping included 30 malignant ovarian endometriotic cyst tissues and 30 corresponding eutopic endometrium tissues from the endometriosis-associated ovarian carcinoma (EAOC) group, 19 benign ovarian endometriotic cyst tissues and 22 corresponding eutopic endometrium tissues from the endometriosis (EM) group and 22 normal eutopic endometrium tissues from the control endometrium (CE) group. RUNX3 methylation status was determined by methylation-specific PCR and bisulfite sequencing, while levels of RUNX3 and ERα protein expression were evaluated using immunohistochemistry. The percentage of RUNX3 methylation and negative RUNX3 protein expression in the malignant ovarian endometriotic cysts from the EAOC group was significantly higher than that in the benign ovarian endometriotic cysts from the EM group. The percentage of RUNX3 methylation and negative RUNX3 protein expression in the eutopic endometrium from the EAOC group was significantly higher than that in the EM and CE groups. An inverse correlation between positive RUNX3 protein expression and methylation was observed and a positive correlation was shown between RUNX3 methylation and ERα protein expression. In the malignant ovarian endometriotic cysts from the EAOC group, there was no significant correlation between methylation frequency of the RUNX3 gene and histological type. However, the percentage of RUNX3 gene methylation was significantly higher in the tissue samples from patients with surgical stage IC EAOC than the percentage in patients with stage IA and IB disease. These results suggest that RUNX3 inactivation by promoter hypermethylation plays a role in the progression of malignant transformation of ovarian EM and is closely related to estrogen metabolism. Negative protein expression and abnormal RUNX3 methylation in the eutopic endometrium could be used as diagnostic markers in patients with ovarian EM who may be at an increased risk of developing EAOC.

Potential role of aromatase inhibitors in the treatment of endometriosis

Endometriosis is an estrogen-dependent chronic inflammatory disease affecting 5%–10% of reproductive-age women, with a prevalence of 5%–50% in infertile women and >33% of women with chronic pelvic pain. Third-generation aromatase inhibitors (AIs) are approved adjuvants for the treatment of estrogen receptor-positive breast cancer. Molecular studies have revealed the presence of aromatase P450, the key enzyme in the biosynthesis of ovarian estradiol, inside the endometriotic tissue, indicating local synthesis of estradiol. Thereby, AIs represent an appealing medical option for the management of different aspects of this enigmatic disease, especially pelvic pain and infertility. Accordingly, this review aims to evaluate the potential role of AIs in the treatment of endometriosis-associated symptoms, mainly pain and infertility. Notably, several studies have demonstrated that the combination of AIs with conventional therapy as oral contraceptive pills, progestins, or gonadotropin-releasing hormone analogs can be used to control endometriosis-associated pain and pain recurrence in premenopausal women, particularly those with pain due to rectovaginal endometriosis refractory to other medical or surgical treatment. Some case reports have shown promising results in the treatment of postmenopausal endometriosis as first-line treatment, when surgery is contraindicated, or as second-line treatment in the case of postoperative recurrence. Third-generation AIs, especially letrozole, have challenged clomiphene citrate as an ovulation-induction agent in patients with polycystic ovary syndrome and in cases of unexplained infertility. However, few studies are available regarding the use of AIs to treat endometriosis-associated infertility. Therefore, larger multicenter randomized trials using AIs for the treatment of endometriosis-associated infertility are needed to clarify its effect. The safety of AIs for ovulation induction or superovulation has generated a lively discussion. Data from recent retrospective and prospective studies have supported its safety.

Endometriosis: a life cycle approach?

To improve the still fragmented understanding of endometriosis, a life cycle approach was adopted that revealed unexpected aspects of the natural history of the disease throughout a woman's life. Three age-related stages of endometriosis are distinguished. In premenarcheal and adolescent endometriosis, 2 types can be distinguished: a classic form that can occur before menarche, and a congenital obstructive form that is caused by uterine anomaly and outflow obstruction. The lesions include superficial peritoneal implants, but adhesions and endometrioma can also occur. It is suggested that premenarcheal and possibly adolescent endometriosis develop by activation of resting stem cells shed at the time of neonatal retrograde uterine bleeding. In the adult, endometriosis can be related to uterine preconditioning by cyclic menstruations acting as a priming mechanism for deep placentation. In adult life, the typical lesions are peritoneal, ovarian, and deep or adenomyotic endometriosis. More recently, endometriosis has been associated with endometrial dysfunction and myometrial junctional zone hyperplasia. These uterine changes can be linked with some major obstetrical syndromes. In postmenopause, endometriosis can develop or be reactivated both in the presence or absence of exogenous estrogens and can spread to a variety of organs and structures causing constrictive lesions.

Endometriosis: a disease that remains enigmatic

Endometriosis, a gynecologic pathology, is defined by the presence of a tissue similar to uterine endometrium, which is located in places other than physiologically appropriate. These endometrial heterotopic islets contain glands and stroma and are functionally capable of responding to exogenous, endogenous, or local hormonal stimuli. Endometriosis affects 8%-10% of women of reproductive age; in 30% of the women, the condition is associated with primary or secondary infertility. In several instances, endometriosis persists as a minimal or mild disease, or it can resolve on its own. Other cases of endometriosis show severe symptomatology that ends when menopause occurs. Endometriosis can, however, reactivate in several postmenopausal women when iatrogenic or endogenous hormones are present. Endometriosis is occasionally accompanied by malignant ovarian tumors, especially endometrioid and clear cell carcinomas. Its pathogenesis is widely debated, and its variable morphology appears to represent a continuum of individual presentations and progressions. Endometriosis has no pathognomonic signs or symptoms; it is therefore difficult to diagnose. Because of its enigmatic etiopathogenesis, there is currently no satisfactory therapy for all patients with endometriosis. Treatments include medications, surgery, or combined therapies; currently, the only procedures that seem to cure endometriosis are hysterectomy and bilateral salpingo-oophorectomy. In this paper, we review the most controversial and enigmatic aspects of this disease.

Endometriosis-associated ovarian cancer: a review of pathogenesis

Endometriosis is classically defined as the presence of endometrial glands and stroma outside of the endometrial lining and uterine musculature. With an estimated frequency of 5%–10% among women of reproductive age, endometriosis is a common gynecologic disorder. While in itself a benign lesion, endometriosis shares several characteristics with invasive cancer, has been shown to undergo malignant transformation, and has been associated with an increased risk of epithelial ovarian carcinoma (EOC). Numerous epidemiologic studies have shown an increased risk of EOC among women with endometriosis. This is particularly true for women with endometrioid and clear cell ovarian carcinoma. However, the carcinogenic pathways by which endometriosis associated ovarian carcinoma (EAOC) develops remain poorly understood. Current molecular studies have sought to link endometriosis with EAOC through pathways related to oxidative stress, inflammation and hyperestrogenism. In addition, numerous studies have sought to identify an intermediary lesion between endometriosis and EAOC that may allow for the identification of endometriosis at greatest risk for malignant transformation or for the prevention of malignant transformation of this common gynecologic disorder. The objective of the current article is to review the current data regarding the molecular events associated with EAOC development from endometriosis, with a primary focus on malignancies of the endometrioid and clear cell histologic sub-types.

Identification of common mechanisms between endometriosis and ovarian cancer

PURPOSE

To determine common molecular markers between endometriosis and ovarian cancer.

METHODS

Patients included women who underwent laparoscopic excision of ovarian endometriotic lesions (n = 7), healthy non-pregnant women with normal pelvises, who underwent excision of normal peritoneum (n = 7). Two epithelial ovarian cancer (EOC) cell lines were also utilized. Expression of transforming growth factor (TGF)-β1, cyclooxygenase (COX)-2, vascular endothelial growth factor (VEGF), estrogen receptor (ER)-1α, progesterone receptor (PR), androgen receptor (AR), and aromatase was evaluated by real-time RT-PCR.

RESULTS

Endometriosis and EOC cells manifested significantly higher mRNA levels of TGF-β1, COX-2, VEGF, ER-1α, AR, and aromatase, while they expressed significantly lower mRNA levels of PR.

CONCLUSIONS

Increased TGF-β1, COX-2, VEGF, ER-1α, AR, and aromatase and decreased PR in endometriotic as well as EOC cells suggests a potential association between these two disease processes. This association is important, as it may reveal common mechanisms for both diseases.

Silent onset of postmenopausal endometriosis in a woman with renal failure in hormone replacement therapy: a case report

Introduction

Postmenopausal endometriosis is a rare form of a common disease, since the absence of estrogenic hormone production should halt disease progression.

Case presentation

We present the case of a 54-year-old Italian Caucasian woman in surgical menopause with a history of ovarian endometriosis, who underwent voluntary hormone replacement therapy for seven years. She developed postrenal renal failure due to bilateral compression of the pelvic ureteral tract caused by two large, deeply infiltrating endometriotic nodules with no pelvic pain. She underwent operative laparoscopy with adhesiolysis of enteroenteric adhesions and excision of the endometriotic nodules encompassing the juxtavesical tract of the ureters, without obtaining improvement of renal failure.

Conclusion

Postmenopausal endometriosis can manifest itself in an unpredictable and potentially very serious manner. It is therefore important to carefully evaluate the risks and benefits of administering hormone replacement therapy to patients with previous endometriosis.

Endometriosis risk in relation to naevi, freckles and skin sensitivity to sun exposure: the French E3N cohort

BACKGROUND

Endometriosis is an important women's health issue, however its aetiology remains unknown. An association between endometriosis and cutaneous melanoma was described, possibly explained through common genetic features. To further investigate this association, we assessed the link between phenotypic traits predisposing to melanoma and the risk of endometriosis.

METHODS

Using a case-control design, we analysed data from 97,215 women of the Etude Epidémiologique auprès de femmes de l'Education Nationale study, a cohort of 98,995 French women insured by a national health scheme mostly covering teachers, and aged 40-65 years at inclusion in 1990. Risk estimates were computed using unconditional logistic regression models.

RESULTS

After adjustment for potential confounding factors, there was a positive dose-effect relationship between risk of endometriosis (reported as surgically ascertained, n = 4241) and skin sensitivity to sun exposure [moderate: odds ratio (OR) 1.09, 95% confidence interval (CI) 0.99-1.19; high: OR 1.22; 95% CI 1.10-1.36; compared with none; Ptrend < 0.0001], number of naevi (few: OR 1.19, 95% CI 1.05-1.35; many: OR 1.37, 95% CI 1.21-1.55; very many: OR 1.59, 95% CI 1.37-1.83; compared with none; Ptrend < 0.0001) and number of freckles (few: OR 1.08, 95% CI 1.00-1.17; very many/many: OR 1.11, 95% CI 1.03-1.20; compared with none; Ptrend = 0.005).

CONCLUSION

This study is, to our knowledge, the first to report a positive dose-effect relationship between the risk of endometriosis and skin sensitivity to sun exposure, and number of naevi and freckles. These data suggest that endometriosis and melanoma may share some genetic features.

Clinicopathologic features of ovarian cancer in patients with ovarian endometrioma

OBJECTIVE

The purpose of this study was to describe the clinicopathologic features of malignant transformation in patients with ovarian endometrioma, their treatment and outcome in the Kinki region, Japan.

PATIENTS AND METHODS

Patients meeting Sampson and Scott's criteria for cancer associated with endometriosis were identified by chart review and pathology reports. This retrospective survey describes 18 women with a history of ovarian endometrioma. These cases were followed as benign ovarian endometrioma before malignant transformation on the basis of imaging findings by gynecologic oncologists or radiologists.

RESULTS

Mean age at presentation of malignant transformation was 45.2 years (range, 36-66 years), and 78% (n=14) were premenopausal women. The pattern of spread was local in 16 (89%), regional in 2 (11%) and distant in 0 (0%). There was a common left-sided predominance. Characteristic histologic findings were 61% clear cell carcinoma. Endometriosis-associated malignancies have a favorable prognosis. The patients showed long latency intervals before developing ovarian cancer (mean, 4.5 years; range, 1-16 years). Among them, subjects (n=10) whose ages are more than 45 years old had shorter latency intervals (mean, 1 year; range, 1-3 years), compared with those (n=8) aged less than 45 years old (mean, 8.4 years; range, 3-16 years).

CONCLUSION

Ovarian endometrioma could be viewed as a neoplastic process, particularly in perimenopausal women.