Chronic Pelvic Pain Caused by Postmenopausal Endometriosis

Abstract

This study was deemed exempt by the Institutional Review Board and did not require its approval. A 38-year-old woman presented with chronic pelvic pain. She reported an extensive surgical history focused primarily on treatment of endometriosis of unknown stage and pelvic pain. This included total hysterectomy and bilateral salpingectomy subsequently followed by bilateral oophorectomy 3 years previously. After her surgical menopause, she underwent 6 additional robotically assisted procedures during a 3-year period, which involved fulguration of endometriosis. She denied having had any previous excisional procedures performed. The possibility of an ovarian remnant could not be ascertained at the time of initial presentation secondary to exogenous estradiol being used for hormone replacement therapy. Given the patient's extensive history of endometriosis treatment, persistent symptoms, and lack of previous excision, the decision was made to proceed with surgical evaluation and treatment. Any endometriosis encountered would be excised, and assessment for ovarian remnant would be performed. Intraoperative evaluation revealed multiple areas visually suspicious for endometriosis (Fig. 1, Fig. 2). All areas of concern for endometriosis were excised and a full pelvic peritonectomy was performed. The infundibulopelvic ligaments were identified, relegated at their origins, and excised to ensure no residual ovarian tissue was left in situ (Fig. 3). Pathology confirmed the presence of endometriosis and no ovarian remnant.Fig. 2Fibrosis and lesions visually consistent with endometriosis involving the left abdominal wall. Evidence of previous left salpingo-oophorectomy present.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig. 3Pelvis after completion of excision of endometriosis, pelvic peritonectomy and removal of infundibulopelvic ligaments bilaterally.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Postoperatively, the patient was continued on estrogen hormone replacement therapy to decrease overall morbidity and mortality. She reported rapid improvement in pain for several months. With increased activity, the patient experienced new onset of periumbilical pain. Physical examination revealed myofascial dysfunction resulting in pain in the pelvic floor and abdominal wall. Pelvic floor physical therapy and cyclobenzaprine were recommended and resulted in further improvement in her pain. Endometriosis is diagnosed in the menopausal time frame in 2%–5% of all cases [1Oxholm D Knudsen UB Kryger-Baggesen N Ravn P Postmenopausal endometriosis.Acta Obstet Gynecol. 2007; 86: 1158-1164Crossref PubMed Scopus (44) Google Scholar]. In women with previous hysterectomy and bilateral salpingo-oophorectomy, 8.3% required a subsequent surgery within 7 years [2Shakiba K Bena JF McGill KM Minger J Falcone T Surgical treatment of endometriosis: a 7-year follow-up on the requirement for further surgery.Obstet Gynecol. 2008; 111: 1285-1292Crossref PubMed Scopus (171) Google Scholar]. Although endometriosis in menopausal patients can be stimulated by hormone replacement therapy, this disease process has also been noted in patients without any exogenous hormone administration. [1Oxholm D Knudsen UB Kryger-Baggesen N Ravn P Postmenopausal endometriosis.Acta Obstet Gynecol. 2007; 86: 1158-1164Crossref PubMed Scopus (44) Google Scholar]. Medical therapy options for treatment of menopausal endometriosis are limited because of natural changes in the hypothalamic-pituitary-ovarian pathway in this population [2Shakiba K Bena JF McGill KM Minger J Falcone T Surgical treatment of endometriosis: a 7-year follow-up on the requirement for further surgery.Obstet Gynecol. 2008; 111: 1285-1292Crossref PubMed Scopus (171) Google Scholar]. Specifically, aromatase inhibitors can be effective, whereas gonadotropin-releasing hormone agonists, progestins, and danazol are ineffective [3Polyzos NP Fatemi HM Zavos A et al.Aromatase inhibitors in post-menopausal endometriosis.Reprod Biol Endocrinol. 2011; 9: 90Crossref PubMed Scopus (24) Google Scholar]. For postmenopausal women with endometriosis, the first-line treatment should be surgical excision [3Polyzos NP Fatemi HM Zavos A et al.Aromatase inhibitors in post-menopausal endometriosis.Reprod Biol Endocrinol. 2011; 9: 90Crossref PubMed Scopus (24) Google Scholar]. Excision of remaining endometriosis is effective in relieving pain in most patients [4Redwine DB Endometriosis persisting after castration: clinical characteristics and results of surgical management.Obstet Gynecol. 1994; 83: 405-413PubMed Google Scholar, 5Clayton RD Hawe JA Love JC Wilkinson N Garry R Recurrent pain after hysterectomy and bilateral salpingo-oophorectomy for endometriosis: evaluation of laparoscopic excision of residual endometriosis.Br J Obstet Gynaecol. 1999; 106: 740-744Crossref PubMed Scopus (40) Google Scholar]. Postmenopausal endometriosis should be considered in surgically, medically, and naturally menopausal women presenting with chronic pelvic pain and symptoms consistent with endometriosis.