CHRONIC PELVIC PAIN

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/

Depression in women with endometriosis linked to chronic pain

Depression in women with endometriosis linked to chronic pain

By I.Soussis MD
The complex relationship between endometriosis and depression in women is largely determined by chronic pelvic pain, a systematic review has found.

According to the researchers, raising awareness among physicians on the nature of this relationship, which “is arguably more complex than a direct cause-effect relationship,” is essential to finding the best course of treatment and improving the quality of life of women with endometriosis.

The review study, “Depressive symptoms among women with endometriosis: a systematic review and meta-analysis,” was published in the American Journal of Obstetrics & Gynecology.

Endometriosis, a chronic disease caused by the abnormal growth of endometrium outside the uterus, is estimated to affect approximately 10 percent of women of reproductive age.

The disorder is mainly associated with infertility and chronic pelvic pain, but patients may also experience painful sexual intercourse (dyspareunia), painful or irregular menstrual cycles (dysmenorrhea), painful bowel movements (dyschezia), psychological issues, and overall low quality of life.

Symptoms of depression are significantly more common among individuals with chronic pain. Therefore, “an association between endometriosis and depression may be reasonably expected,” the researchers say. However, so far, no study explored this potential relationship thoroughly.

In this review study, the authors established two goals: first, to determine if there is a link between endometriosis and depression; and second, to assess whether depression is more common in women with chronic pelvic pain associated with endometriosis than in women with endometriosis but without pelvic pain and women with pelvic pain but without endometriosis.

The review included studies published over the past 30 years focused on comparing the clinical outcomes of women with and without endometriosis, or, among those with endometriosis, women with and without chronic pelvic pain.

A meta-analysis from 24 studies involving a total of 99,614 women revealed that those with endometriosis had significantly higher levels of depression than those not affected by the disease. This effect was even stronger when the researchers performed the same type of analysis on 11 studies (1,070 women) comparing between healthy women and those with endometriosis.

Further analysis showed that women with endometriosis who also experienced chronic pelvic pain had higher levels of depression than those who did not report pain.

However, no significant differences were found between women with endometriosis and chronic pain and those with chronic pain not affected by the disease.

“The findings of our multiple meta-analyses provide converging evidence that chronic pain, rather than endometriosis itself, is the main determinant of depressive symptoms,” the researchers wrote. “Screening for psychiatric symptoms among women with endometriosis has therefore been advocated, and our findings would suggest to particularly direct it to those with chronic pain.”

“Future studies into possible modulators of the association will hopefully provide further insights about how to improve the quality of life of women with endometriosis and/or pelvic pain,” they concluded.

 

My opinion

In our effort to provide personalized care in patients with endometriosis, the impact of chronic pelvic pain on the quality of life should be taken into consideration. Such patients might benefit from psychological assessment and possibly treatment for depression.

Read more:

https://www.ncbi.nlm.nih.gov/m/pubmed/30419199/

image credit https://www.medicalnewstoday.com/articles/301822.php

Botox injection reduces chronic pelvic pain in endometriosis

Botox injection reduces chronic pelvic pain in endometriosis

By I. Soussis MD, MSc, FRCOG

Consultant Obstetrician- Gynaecologist, Fertility Specialist

An injection of botulinum toxin, commonly known as Botox, helped relieve chronic pelvic pain in women with endometriosis for up to 11 months, according to researchers.

The results of their study were presented at the 2018 Annual Meeting of the American Academy of Neurology in a presentation titled, “Botulinum Toxin Treatment of Chronic Pelvic Pain in Women with Endometriosis.”

Pelvic pain often persists despite optimal surgical/hormonal management in women with endometriosis, often associated with pelvic floor spasm.

Researchers offered women suffering from endometriosis-associated chronic pelvic pain an open injection of the botulinum toxin, called onabotulinumtoxinA, or onaBoNTA. Patients were participating in an ongoing placebo-controlled trial with the toxin.

Ten out of 13 women participating in the study requested the onaBoNTA injection, which was injected into the pelvic floor muscle in 100-unit doses (25 units/cc).

Patients were followed for at least three months after the injection and researchers assessed the injection effects by measuring the changes in spasm, pain, and disability.

At the beginning of the study (before their injection), eight of the 10 women who decided to get the injection had spasms in their pelvic muscles, accompanied by intense pain.

One month after the onaBoNTA injection, spasm rates were significantly reduced or completely absent from all patients. Most of the patients (8 out of 10) reported only mild or even an absence of pain. Their median score on a scale for measuring pain intensity, called  the visual analogue scale, or VAS, was 1.5.

The VAS scale goes from “no pain” (score of 0) and “pain as bad as it could be” or “worst imaginable pain” (the scale can be as high as 100). As a result, half of the women reduced their need for pain medication.

The disability was also improved in three of five women who showed a moderate disability prior to injection.

The effects of the onaBoNTA injection faded in three women six to 11 months after the injection. The three requested a new shot of onaBoNTA. Adverse events were mild and transient.

Overall, these findings show that “injection of onaBoNTA reduced pain, spasm, and disability for up to 11 months,” researchers wrote.

“Utility of botulinum toxin for endo-CPP (endometriosis-associated chronic pelvic pain) merits evaluation in controlled clinical trials,” the study concluded.

 

Read more: http://n.neurology.org/content/90/15_Supplement/P2.098

Source: https://endometriosisnews.com/2018/05/02/aan2018-botulinum-toxin-may-help-reduce-pelvic-pain-endometriosis/

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