Rare Clinical Presentation of Postmenopausal Endometriosis: A New Perspective

Abstract

Endometriosis affects 2-5 % of postmenopausal women with menopause hormone therapy and is less common in women without treatment with exogenous estrogen or tamoxifen. Postmenopausal endometriosis has more unknown aspects in its pathogenesis and clinical manifestation than in the case of premenopausal patients. The aim of this review was to summarize the clinical presentation of rare cases of endometriosis, including deep infiltrating (DIE) and extragenital endometriosis, in women. The symptoms of endometriosis in the post-reproductive age are more heterogeneous than in women of childbearing age, often resembling symptoms of gastrointestinal tumors or urinary tract diseases. We summarize cases of endometriosis of the intestines, liver, pancreas, and stomach, as well as endometriosis of the urinary tract and skin, with nongynecological manifestations. We also describe the pathogenesis of endometrial tissue activity in the context of reduced estrogen levels after menopause, which is also not clear, and demands more molecular and genetic studies. NAD+-dependent deacetylases called Sirtuins are metabolic sensors for maintaining body homeostasis. In the context of endometriosis, Sirtuins are being studied for their potential role in modulating inflammation, cell proliferation, and sex hormone sensitivity, but their role in postmenopausal endometriosis is not well researched. Treatment in postmenopausal women includes mostly for now surgery, depending on the location of the lesion, and aromatase inhibitors. The complete genetic and epigenetic profile in women post-reproductive age is needed to propose target therapy, especially in severe cases such as endometriosis that is deeply infiltrating and located outside the pelvis.

Deep pelvic endometriosis causing ureteral obstruction

“…Deep pelvic endometriosis is a chronic condition characterized by endometriotic implants that extend 5 mm beneath the peritoneum [ 3 ]. These implants can involve the urinary tract, and most commonly the bladder (15%) and ureters (4.5%), accounting for only 1% of all endometriosis patients but up to 53% of patients with deep infiltrating endometriosis [ 4 ].…”

“…In cases such as ours, where the risk of surgery was higher than the risk of malignant formation, surgery should not be performed until the lesions begin to show malignant characteristics. Additionally, letrozole and anastrozole have been found effective in reducing symptoms and the size of endometriotic lesions, but there is a risk of associated side effects [ 3 ]. In our case, despite severe obstruction and hydronephrosis, the patient was asymptomatic for three years.…”

Postmenopausal endometriosis: a challenging condition beyond menopause

“…• May offer protective effects on breast [50][51][52] • Helps prevent osteoporosis • Effective in managing vasomotor symptoms of menopause • Demonstrates an acceptable cardiovascular safety profile 44,45 • Exacerbate endometriosis and malignant transformation 53,54 • Associated with an increased risk of venous thromboembolism • May lead to side effects such as muscle spasms, gastrointestinal disorders, oropharyngeal pain, neck pain, and dizziness 44 Surgical therapy…”