About Menopause

1. Endometriosis & Menopause
By
Dr Chitra Gupta

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.

20. • MANAGEMENT

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.

24. Aromatase Inhibitors
• INDICATIONS…
• 1. Postmenopausal pts with post surgical recurrence.
• 2. Where surgery is contraindicated.

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.

36. • THANK YOU.