Clinical Management of Endometriosis in Menopause: A Narrative Review
Abstract
:1. Introduction
2. Diagnosis
2.1. Evaluation of Postmenopausal Pelvic Pain
2.2. Imaging of Endometriosis
2.3. Laborotory Assessment: Biomarkers
3. Indications for Surgery
4. Hormone Replacement Therapy
5. De Novo Endometriosis Development
6. Malignant Transformative Potential
7. Conclusions and Future Directions
Author Contributions
Funding
Conflicts of Interest
References
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Condition | Definition | Management |
---|---|---|
Genitourinary syndrome of menopause | An array of symptoms caused by hypoestrogenic changes to the vulva, vagina, urethra, or bladder that are typically seen in postmenopausal women. Also referred to as vulvovaginal atrophy. | Estrogen vaginal cream, vaginal lubricants, and moisturizers |
Pelvic floor tension myalgia | A common type of pelvic pain specific to the pelvic floor. A type of myofascial pain that typically arises from the spasticity, hypersensitivity, and dysfunction of the pelvic floor muscles; fascia/abdominal wall; trigger points; and back pain. | Pelvic floor physical therapy, vaginal suppositories, pelvic floor trigger point injections, and pelvic floor Botox injections |
Pudendal neuralgia | Pelvic pain associated with hypersensitivity to the pudendal nerves which can cause nerve entrapment and inflammation. Pain is typically increased with sitting and can be caused by previous pelvic trauma, childbirth, or changes related to age. | Pelvic floor physical therapy, vaginal suppositories, pudendal nerve block, and pudendal neurolysis surgery |
Pelvic adhesions | Scar tissue and adhesions in the pelvis from prior surgery or inflammatory conditions such as endometriosis. | Consideration of surgery for the lysis of adhesions (controversial) |
Vulvodynia | Vulvar pain, likely idiopathic in nature, that occurs for three months or more. Hypersensitivity to the vulva with sitting, palpation, and with activity. | Estrogen vaginal cream, topical lidocaine, topical neuromodulating medications, and vestibulectomy |
Pelvic congestion syndrome | Pelvic pain associated with dilated or engorged pelvic vascular structures. This can also be associated with Nutcracker syndrome and vulvovaginal varicostities. | Progestins, embolization or coiling of abnormal vasculature, and consideration of surgery |
Painful bladder syndrome | Chronic bladder pain, also known as interstitial cystitis, which significantly impacts the quality of life in men and women. Etiology is unknown and likely multi-factorial. | Lifestyle modifications and avoidance of bladder irritants, anti-histamine medications, bladder instillations, bladder Botox injections, and bladder hydrodistention |
Coccydynia | Chronic coccyx and/or tailbone pain causing tenderness and localized pain to the coccyx primarily with sitting and the supine position. Symptoms may also lead to pelvic floor dysfunction, dyspareunia, pelvic floor tension myalgia, and defecation disorders. | Pelvic floor physical therapy, coccyx trigger point injections, and ganglion impar block |
Endometriosis | Endometrial glands and stomas found outside of the endometrial cavity that can cause pelvic pain, dyspareunia, menorrhagia, dysmenorrhea, potential infertility, and chronic pain. | Hormone suppression (OCPs, progestins, annd GnRH analogs), and surgical excision |
Adnexal masses | Masses typically seen in the adnexal space or on the ovary; may be cystic lesions or tumors that range from simple to complex, benign to malignant. | Surgical excision |
Vulvar dermatoses | Dermatitis to the vulva that is typically inflammatory in nature. Symptoms can include erythema, prurutitis, chronic irritation, and/or vulvar lesions or rash. | Estrogen vaginal cream, topical steroids, vaginal laser therapy, and vaginal platelet-rich plasma (experimental) |
Vaginal cuff pain | Persistent tenderness, burning, or discomfort at the center or apexes of the vaginal cuff. This may be related to vaginal adhesions, previous pelvic radiation, or atrophy. | Pelvic floor physical therapy, vaginal suppositories, vaginal cuff trigger point injections, consideration of surgical revision of cuff (controversial) |
Ovarian remnant syndrome | Ovarian tissue seen in a patient who previously underwent oophorectomy. This can lead to pelvic pain and adnexal masses. | Surgical excision of the remnant ovarian tissue |
O-RADS Score | Risk Category | U/s Features | MRI Features |
---|---|---|---|
O-RADS 0 | Incomplete evaluation | N/a | N/a |
O-RADS 1 | Normal ovary | Risk of malignancy: N/a
| Risk of malignancy: N/a
|
O-RADS 2 | Almost certainly benign | Risk of malignancy: <1%
| Risk of malignancy: <0.5%
|
O-RADS 3 | Low risk | Risk of malignancy: 1–10%
| Risk of malignancy: <5%
|
O-RADS 4 | Intermediate risk | Risk of malignancy: 10–50%
| Risk of malignancy: 50%
|
O-RADS 5 | High risk | Risk of malignancy: ≥50%
| Risk of malignancy: 90%
|
Author | Year | Pathology | Case Description |
---|---|---|---|
Vorstman [63] | 1983 | Benign bladder endometrioma | A 64-year-old female with prior hysterectomy and no current HRT use presented with hematuria and stress urinary incontinence. A cystic mass was noted at the bladder dome and confirmed to be endometriosis with a bladder biopsy. She underwent partial cystectomy, left oophorectomy, and Marshall-Marchetti procedure. |
Ismail [64] | 1997 | Benign ovarian endometrioma | A 52-year-old female with breast cancer (using tamoxifen)and no prior history of endometriosis or HRT use underwent hysterectomy with BSO due to vaginal bleeding. She had a cystic 10 cm ovarian mass. |
Kurioka [65] | 1999 | Benign ovarian endometrioma | A 55-year-old postmenopausal woman without known endometriosis or HRT use presented with a partially solid ovarian mass. She underwent an abdominal hysterectomy with BSO. |
Deval [66] | 2002 | Benign endometriosis | A 69-year-old woman with pelvic pain, constipation, and progressive weight loss with a 15 cm lesion causing compression of the sigmoid colon. There was no prior history of endometriosis or HRT use, and tumor markers were normal. She underwent laparotomy with radical hysterectomy, BSO, colon resection with sigmoid end-colostomy and Harmann’s pouch creation. |
Goumenou [67] | 2003 | Benign endometriosis | A 67-year-old woman with pelvic pain and deep dyspareunia, prior hysterectomy, and she had been using estrogen HRT along with testosterone implants. Imaging showed a 2.9 cm cystic left ovarian mass, with normal Ca-125. Laparoscopy showed left ovarian endometriosis, extensive peritoneal implants, a large retroperitoneal mass, and obliteration of the posterior cul-de-sac. |
Popoutchi [68] | 2008 | Benign rectal endometriosis | A 74-year-old female presented hematochezia and tenesmus; with prior hysterectomy and BSO and no prior HRT use. Imaging revealed a large bowel obstruction, and colonoscopy showed a friable rectal tumor, with pathology consistent with endometriosis. The patient underwent rectosigmoidectomy with protective transversotomy, and ultimately returned for end colostomy due to the stenosing recurrence of the rectum. |
Manero [69] | 2009 | Benign ovarian endometrioma | A 62-year-old-female with no prior history of endometriosis or HRT use presented with pelvic pain. Imaging revealed a 4.4 cm left ovarian mass, with normal tumor markers. Laparoscopic BSO was performed. |
Maeda [70] | 2009 | Benign bladder endometriosis | A 65-year-old woman with painless hematuria and abdominal pain, with prior hysterectomy and no prior HRT use. Imaging showed a vesical polypoid mass, and cystoscopic biopsy and transurethral resection of the mass revealed endometriosis. |
Agarwal Sharma [71] | 2016 | Benign ovarian endometrioma | A 69-year-old woman with abdominal distention and short-term leg swelling. Ca-125 was elevated to 120 u/mL, and imaging showed a 25 cm cystic pelvic mass which was suggestive of malignancy with peritoneal carcinomatosis. She underwent exploratory laparotomy with cytoreduction, and findings showed diffuse endometriosis along the peritoneal surfaces in addition to the large ovarian mass. |
Ianieri [72] | 2017 | Benign endometriosis | A 63-year-old female with abdominal pain and limb swelling, who was noted to have a retroperitoneal mass causing deep vein thrombosis because of the extrinsic compression of the left iliac vein. Laparotomy with endometriosis excision was performed. |
Solima [73] | 2019 | Benign endometriosis | A 60-year-old postmenopausal woman with no prior HRT use, and no known endometriosis or chronic pelvic pain presented with a rectovaginal mass. Imaging revealed a mass involving the uterus, posterior bladder wall, and rectum, and a cystic lesion was seen in the bladder trigone during cystoscopy. She underwent laparoscopic BSO and bladder biopsy. |
Naem [74] | 2020 | Benign abdominal endometrioma | A 67-year-old woman presented with bowel obstruction and right-sided hydronephrosis in the setting of a 17 × 26 cm abdominal mass. The patient underwent laparotomy with the en-bloc resection of the mass. |
Devasilpa [75] | 2022 | Benign ovarian endometrioma | A 52-year-old postmenopausal patient presented with abdominal distention, and imaging showed a 30 × 13 × 20 cm right ovarian cystic mass. Ca-125 was normal and she was not previously using HRT. Laparotomy with right salpingo-oophorectomy was performed, with extrusion of 5 L of chocolate cyst fluid. |
Zografou [76] | 2023 | Benign ovarian endometrioma | A 60-year-old previously healthy female presented with a 26 cm ovarian mass. Pre-operative Ca-125 was 512.9 U/mL, and all other labs were normal. The patient underwent laparotomy with BSO. |
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Dave, D.; Page, H.E.; Carrubba, A.R. Clinical Management of Endometriosis in Menopause: A Narrative Review. Medicina 2024, 60, 1341. https://doi.org/10.3390/medicina60081341
Dave D, Page HE, Carrubba AR. Clinical Management of Endometriosis in Menopause: A Narrative Review. Medicina. 2024; 60(8):1341. https://doi.org/10.3390/medicina60081341
Chicago/Turabian StyleDave, Dhruva, Heidi E. Page, and Aakriti R. Carrubba. 2024. "Clinical Management of Endometriosis in Menopause: A Narrative Review" Medicina 60, no. 8: 1341. https://doi.org/10.3390/medicina60081341