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Endometriosis can occur after menopause

Endometriosis can occur after menopause

Despite being rare, endometriosis can appear or come back after menopause.

Doctors should be aware of this, particularly if there are complaints of pelvic pain or heavy bleeding, and they must not underestimate the risk of the disease progressing into cancer, an opinion piece written by several obstetrician-gynecologists says.

Researchers also call attention to a major therapeutic dilemma: Should a doctor prescribe hormonal replacement therapy (HRT) to a woman experiencing menopause symptoms, given that this may raise her risk of having endometriosis come back or degenerate into cancer?

The article, “Endometriosis and the menopause: why the question merits our full attention,” appeared in the journal Hormone Molecular Biology and Clinical Investigation.

Post-menopausal endometriosis is a rare condition but is a reality,” the authors stated.

As an estrogen-dependent disease, endometriosis primarily affects women of reproductive age, its activity lessening or even regressing at the onset of menopause.

However, there have been several reports of cases that demonstrate the disease may still develop at this time, in the absence of menstrual cycles and in a low-estrogen environment. During menopause, the ovaries’ activity drops drastically, including their capacity to secrete hormones.

The fact that endometriosis can appear in such conditions sheds doubt on Sampson’s theory of retrograde bleeding in explaining the disease origin, and implicates other mechanisms, researchers say.

Doubt persists, however, as to whether endometriosis persists into the post-menopausal period, whether it comes back from a pre-existing disease or if it can develop for the first time after menopause.

In any case, researchers propose several sources of estrogen in postmenopausal women that might serve as risk factors for endometriosis: conditions such as obesity, intake of plant-derived estrogens (phytoestrogens), the use of HRT or tamoxifen, and the production of estrogen by endometriosis lesions themselves.

Tamoxifen, a medication used for breast cancer, acts as an anti-estrogen in the mammary tissue, but as an estrogen-stimulating agent in cholesterol metabolism, bone density, and cell proliferation in the endometrium.

HRT, a common treatment used to relieve menopause symptoms, consists of taking hormone supplements, including estrogen, to restore some of the hormonal levels that decrease during menopause.

Other factors that may play a role include stress, genetic factors, hypothyroidism, or fatty acids (unsaturated omega 3).

Another factor to take into account is that HRT may increase the risk of endometriosis symptoms and disease recurrence after surgery to treat severe symptoms. If there are residues of endometriosis lesions before starting HRT, this risk may increase, particularly if the disease was more severe and surgery was incomplete.

Therefore, before prescribing HRT it is imperative “to weigh the risks and benefits,” researchers say.

The authors also call clinicians’ attention to not forgetting the risk of progression into cancer with or without HRT.

Endometriosis is a benign condition, but about 1% of cases are estimated to develop into cancer, most commonly in the ovary, but also in the bowel and even the lung.

Clinicians should be particularly attentive if a woman reports pelvic pain — dysmenorrhea, dyspareunia or chronic pelvic pain — and heavy bleeding. Diagnosis can be done through patient history, clinical examinations and using ultrasound and magnetic resonance imaging (MRI). However, laparoscopy (keyhole surgery) is the only way to fully confirm a diagnosis of cancer.

The first-line treatment for new-onset symptomatic post-menopausal endometriosis should be surgery because of diagnosis uncertainty and the risk of cancer. Medical therapy can be an alternative if pain comes back after surgery or if surgery is contraindicated, including aromatase inhibitors and levonorgestrel or gestodene, two hormonal contraceptives.

Source:https://www.degruyter.com/view/j/hmbci.ahead-of-print/hmbci-2018-0071/hmbci-2018-0071.xml

https://endometriosisnews.com/2019/04/02/doctors-must-be-aware-that-endometriosis-can-occur-after-the-menopause-article-says/

Endometriosis may double the risk for ovarian cancer

Endometriosis may double the risk for ovarian cancer

By I. Soussis MD

Women with endometriosis are 1.9 times more likely to develop ovarian cancer, but are at no higher risk for endometrial and cervical cancers, a meta-analysis suggests.

The study, “Impact of endometriosis on risk of ovarian, endometrial and cervical cancers: a meta-analysis,” was published in the journal Archives of Gynecology and Obstetrics.

While endometriosis is considered a benign gynecologic disease, it displays features similar to those seen in malignant tumors, including:

  • the ability to invade other tissues

  • a high rate of new blood vessel formation

  • development of local and distant sites of lesions

These characteristics of endometriosis rendered its classification as behaving similar to tumor-like lesions by the World Health Organization, and growing evidence suggests that the condition may represent an initial stage of tumor progression.

While some studies have associated endometriosis with an increased risk for developing different gynecologic tumors, namely ovarian and endometrial cancers, the results are conflicting.

Therefore, a team of researchers in China performed a meta-analysis to investigate the link between endometriosis and the risk for three gynecological cancers: ovarian, endometrial, and cervical.

Out of 8538 studies retrieved from several databases, they analyzed 25 studies, which included 15 cohort and 10 case-control studies. These studies had been conducted in different countries, including Taiwan, the U.S., Australia, Sweden, Denmark, the Netherlands, Japan, Canada, and Spain, with one study involving joint participation of multiple countries.

The researchers evaluated the risk factor between endometriosis and ovarian cancer in 23 studies, between endometriosis and endometrial cancer in 9 studies, and between endometriosis and cervical cancer in 3 studies.

They found that endometriosis was associated with an increased risk (1.9 times) for developing ovarian cancer. In fact, the ovary is one of the major target organs for the malignant transformation of endometriosis. An integrated analysis of different studies revealed a great overlap between the genetic alterations of both endometriosis and ovarian cancer.

Of note, researchers found that endometriosis increased the risk for developing some subtypes of ovarian cancer: endometrioid and clear-cell type.

No clear evidence supports a link between endometriosis and the risk for endometrial cancer, and endometriosis was not associated with an increased risk for cervical cancer.

Despite the authors’ efforts in making a robust comparison of the different studies using rigorous selection criteria, they were limited to the number of available articles about each cancer type. There were more ovarian cancer studies available, which could have influenced the observations to some extent, the study noted.

There is insufficient evidence to support the theory of endometriotic lesions as a precancerous lesion,” the researchers wrote.

Their meta-analysis suggests that endometriosis is a potential risk factor for developing ovarian cancer, but additional studies are required to understand further if endometriotic lesions are precancerous.

If endometriosis is considered a precancerous lesion, the current treatment management needs to be modified,” the researchers concluded, noting that patients with endometriosis need to be closely observed and rechecked regularly to prevent malignant changes.

My opinion

The association between endometriosis and clear-cell cancer of the ovary and endometrioid ovarian cancer is well established. This meta-analysis confirms it and also clarifies that there is no increased risk between endometriosis and endometrial and cervical cancer.

Women with endometriosis should have life-long regular follow up by their doctors.

Source:

https://endometriosisnews.com/2019/01/24/endometriosis-may-increase-risk-ovarian-cancer-not-endometrial-cervical-cancers-study/

Read more:

https://link.springer.com/article/10.1007%2Fs00404-018-4968-1

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