Recurrence of Endometriosis Associated with Hormone Replacement Therapy in a Woman Following Hysterectomy

Authors: N. Mendoza, L. Hortas, A. Suarez, F. Vergara, A. Herruzo.

The following article appeared in European Menopause Journal, 4(4):149-151, 1997. © 1997 PMSI Bugamor B.V.

Introduction
Endometriosis is a chronic disorder with potentially far-reaching consequences for women's fertility and working activities. Although many authors have suggested that endometriosis is estrogen dependent, its pathogenesis still remains unknown and, in most cases, its treatment is extremely difficult.[1]

A history of endometriosis has been considered for many years to be contraindicated in postmenopausal women on hormonal replacement therapy (HRT). This is because of the possibility of reactivating the process.[2,3] Moreover, postmenopausal women on HRT after surgical treatment (hysterectomy and bilateral oophorectomy) are also at risk of recurrent endometriosis either from implants in the surgical site or ex novo formations on other abdominal organs.[4,5]

On the other hand, the beneficial effects of HRT on bone mineral density, preventing osteoporosis, increased protection against cardiovascular disease, and overall improvement of the quality of life in postmenopausal women, have been well established.[6-10] A relatively new drug in HRT is a synthetic steroid known as Tibolone. This formulation combines the favourable effects of estrogens, progestagens and androgens and does not cause endometrial proliferation.[11]

Case Report
A 45 year old women (para2) underwent hysterectomy and bilateral salpingo-oophorectomy due to endometriosis (stage four of the AFS classification) with histologically verified involvement of both ovaries. After surgery the patient was treated with a GnRH analogue. She requested hormone replacement therapy for climacteric symptoms, having no other contraindications for HRT. At four months post surgery Tibolone was administered at a dose of 2.5 mg/day. Eight months after commencing treatment she returned with abdominal pain similar to that experienced prior to surgery. Upon bimanual exploration, an approximately 7 cm mass was palpated, which was confirmed by ultrasound (Figure 1). A recurrence of endometriosis was suspected and HRT was suspended. An ultrasound-guided puncture was performed, obtaining "chocolate-like fluid" from the cyst. Histology was not performed. The patient refused further surgery but accepted HRT withdrawal. Seven months later, the abdominal pain disappeared and the mass reduced to 3 cm (Figure 2). Despite the reappearance of climacteric symptoms, the patient did not wish to re-initiate HRT.

FIGURE 1 - 7 cm pelvic mass after eight months of HRT.

FIGURE 2 - Reduction of the pelvic mass to 3 cm, seven months after HRT withdrawal.

Comments
There is no agreement on whether estrogen administration in postmenopausal women with previous endometriosis is appropriate. The possibility of recurrence has been the limiting factor for the use of HRT in these patients, even after complete removal of all endometriotic tissue. This is because endometriotic cells can remain inactive for many years but become "activated" upon estrogenic administration.[2-5]

The patient described in this study experienced recurrence of abdominal pain after hysterectomy and bilateral oophorectomy, probably caused by a peritoneal mass. This was both clinically and ultrasonically compatible with a recurrence of endometriosis although histological confirmation was not possible. Therefore, either some remnants of endometriosis tissue might have remained after surgery or endometriosis developed ex novo, as a result of HRT. Several authors have proposed the administration of progestins for 6-12 months prior to surgery, or a delay after surgery prior to commencing estrogen replacement.[4] In this case, HRT was initiated four months after surgery and after administration of the gonadotrophin analogue dose.

A history of endometriosis is not an absolute contraindication for HRT. The recurrence of this illness is extraordinarily infrequent and it usually disappears when HRT is suspended. Due to the beneficial effects of HRT in preventing certain ageing processes and improving the quality of life of postmenopausal women, it should not be rejected in these patients.[10-12] Therefore, HRT with Tibolone can be of value in the therapy of climacteric symptoms in women with endometriosis.

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