Complications of unopposed oestrogen following radical surgery for endometriosis

Abstract

Four cases are presented here of patients who had total abdominal hysterectomy and bilateral salpingooophorectomy for severe endometriosis. All were eventually placed on unopposed oestrogen replacement therapy, two immediately and the other two after a few months. All subsequently developed recurrence of their endometriosis whilst on oestrogen therapy, one developing an endometroid carcinoma. All required surgery and three were placed on continuous oestrogen/progestogen preparation or alternatively tibolone (which has oestrogenic, progestogenic and androgenic properties) postoperatively. No further recurrence of their disease occurred. The literature was reviewed regarding oestrogen therapy for women who have had bilateral oophorectomy. There were various suggestions as to management but no report on using continuous oestrogen/ progestogen or tibolone. We suggest this as a logical form of replacement therapy for patients who have bilateraloophorectomy for severe endometriosis, as unopposed oestrogen therapy can cause recurrence.

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

“…For analysis, case reports and series were divided by these two main outcomes. One case series was included in both outcomes as it described three patients with endometriosis recurrence and one patient with malignant transformation ( Taylor et al , 1999 ).…”

“…Six patients had a history of ‘extensive’ or ‘severe’ endometriosis ( Manyonda et al , 1989 ; Joseph et al , 1994 ; Taylor et al , 1999 ; Badawy et al , 2004 ). Fourteen patients underwent surgical menopause years before presentation ( Skor et al , 1977 ; Stewart and Ireland, 1977 ; Kapadia et al , 1984 ; Ray et al , 1985 ; Manyonda et al , 1989 ; Joseph et al , 1994 ; Taylor et al , 1999 , 2005 ; Badawy et al , 2004 ; Giarenis et al , 2009 ), while only two transitioned naturally to menopause ( Goh and Hall, 1992 ; Chahine et al , 2007 ). One patient entered menopause as a result of premature ovarian insufficiency ( Mattar et al , 2008 ).…”

“…Unopposed oestrogen was implicated in numerous cases of symptom recurrence ( n = 12) ( Skor et al , 1977 ; Stewart and Ireland, 1977 ; Kapadia et al , 1984 ; Ray et al , 1985 ; Manyonda et al , 1989 ; Taylor et al , 1999 , 2005 ; Badawy et al , 2004 ; Giarenis et al , 2009 ). Fewer studies reported recurrence in women who were using combined hormonal preparations (oestrogen and progestagen) ( n = 5) ( Goh and Hall, 1992 ; Joseph et al , 1994 ; Badawy et al , 2004 ; Chahine et al , 2007 ; Mattar et al , 2008 ).…”

“…Fewer studies reported recurrence in women who were using combined hormonal preparations (oestrogen and progestagen) ( n = 5) ( Goh and Hall, 1992 ; Joseph et al , 1994 ; Badawy et al , 2004 ; Chahine et al , 2007 ; Mattar et al , 2008 ). In terms of method of oestrogen administration, oral tablets ( n = 5) ( Skor et al , 1977 ; Stewart and Ireland, 1977 ; Kapadia et al , 1984 ; Ray et al , 1985 ; Goh and Hall, 1992 ), implants ( n = 6) ( Manyonda et al , 1989 ; Taylor et al , 1999 , 2005 ) and patches ( n = 3) ( Badawy et al , 2004 ; Taylor et al , 2005 ) were all reported. Table III provides information on HRT dosages and regimens; however, variability in the level of detail provided by the included case reports and series limits these data.…”

“…Oestradiol implant ( Taylor et al, 1999 ) 11. Oestradiol implant ( Taylor et al , 1999 ) 12. First oestradiol implant, then Evorel 50 patches ( Taylor et al, 2005 ) Combined 13.…”