Perimenapozal ve Postmenapozal Dönemde Endometrioma Yönetimi
Synopsis
Menopoz over aktivitesindeki kayıp sonucu menstrüasyonun kalıcı bir şekilde sonlandığı doğal bir dönemdir.. 12 aylık amenore sonrası dönem ise ‘’postmenopozal’’ dönem olarak adlandırılmaktadır (1). Endometriozis, pelvik ağrıya ve infertliteye neden olan rahim dışında endometriyal dokunun varlığı olarak tanımlanan hastalıktır. Genel olarak üreme döneminde görüldüğü bilinen endometriozisinpostmenopozal dönemde endometriozisprevalansının %2-5 olduğu bilinmektedir.
Postmenopozalendometriozis için risk faktörlerine bakıcak olursak; Obezite, Artık OverSendromu , Cerrahi uygulamalarda overlerin in situ bırakılmasıdır. Endometriozisi olan postmenopozal kadınların kliniğe başvuru nedenlerine bakıldığında diğer yaş gruplarında olduğu gibi hiçbir şikayetin olmamasından hafif-ciddi ağrı yakınmalarına kadar geniş bir klinik spektrumla karşılaşırız.Tanı diğer yaş gruplarına benzer şekilde hastadan alınacak detaylı anamnez, muayene ve tetkiklerdir.
Yapılan çalışmalara rağmen kesin tedavisi netleşmemiştir. Hastalarda tedavi seçeneğini seçerken; hastanın yaşı, klinik semptomları, eşlik eden ek patolojileri, çocuk istemi gibi bir çok durum birklikte değerlendirilerek karar verilmelidir. Postmenopozal hastaları değerlendirirken olası malignite riski de akıldan çıkarılmamalıdır.Postmenopozalendometriozis en sık olarak ağrı ve/veya over kitlesi olarak karşımıza çıkmaktadır. Menopoz döneminde endometriozisin cerrahi tedavisi, özellikle medikal tedaviye göre daha ön planda tutulmaktadır.
Postmenopozalendometriozis nadir görülen bir durumdur, tedavisi cerrahidir. Cerrahiye uygun olmayan adaylar için aromataz inhibitörleri ve progesteron tedavisi rutin kullanıma girmemiştir. Açıklanmayan pelvik ağrısı olan postmenopozalendometriozis varlığının akılda tutulması gerekmektedir.
Menopause is a natural period in which menstruation permanently ends as a result of loss of ovarian activity. The period after 12 months of amenorrhea is called the "postmenopausal" period (1). Endometriosis is a disease defined as the presence of endometrial tissue outside the uterus that causes pelvic pain and infertility. It is known that endometriosis, which is generally seen during the reproductive period, has a prevalence of 2-5% in the postmenopausal period.
If we look at the risk factors for postmenopausal endometriosis; Obesity, Residual Ovary Syndrome, Leaving the ovaries in situ in surgical procedures. When we look at the reasons for applying to the clinic for postmenopausal women with endometriosis, we encounter a wide clinical spectrum, from no complaints to mild to severe pain complaints, as in other age groups. Diagnosis is a detailed anamnesis, examination and tests to be taken from the patient, similar to other age groups.
Despite the studies, the definitive treatment has not been clarified. When choosing the treatment option in patients; The patient's age, clinical symptoms, accompanying additional pathologies, and desire to have children should be evaluated together to make a decision. The possible risk of malignancy should not be forgotten when evaluating postmenopausal patients. Postmenopausal endometriosis most commonly presents as pain and/or an ovarian mass. Surgical treatment of endometriosis during menopause is especially prioritized over medical treatment. Postmenopausal endometriosis is a rare condition, and its treatment is surgical. Aromatase inhibitors and progesterone therapy have not been routinely used for candidates who are not suitable for surgery. The presence of postmenopausal endometriosis with unexplained pelvic pain should be kept in mind.
References
Fagervold, B.,Jenssen M., HummelshojL.,et al. Life after a diagnosiswithendometriosis‐a 15 yearsfollow‐upstudy. Actaobstetricia et gynecologica Scandinavica,2009: 88(8), 914-919.
Guy JM: Edgar Haydon (1859-1942): general practitionerandradiumpioneer. J MedBiogr. 2009, 17: 127-134. 10.1258/jmb.2009.009015
Haas, D, Chvatal, R, Reichert B. Endometriosis: a premenopausaldisease? Age pattern in 42,079 patientswithendometriosis. Arch. Gynecol. Obstet. 2012;286(3), 667–670.
Eskenazi, B. and M.L. Warner, Epidemiology of endometriosis. ObstetGynecolClin North Am, 1997. 24(2): p. 235-58., 3
Meuleman, C., et al., High prevalence of endometriosis in infertilewomenwith normal ovulationandnormospermicpartners. Fertil Steril, 2009. 92(1): p. 68-74
Inceboz, Umit.Endometriosisaftermenopause. Women’s Health.2015;11(5):711-715
Punnonen R, Klemi PJ, Nikkanen V. Postmenopausalendometriosis. Eur J ObstetGynecolReprodBiol. 1980; 11:195-200.
Magtibay PM, Nyholm JL, Hernandez JL, Podratz KC. Ovarianremnantsyndrome. Am J ObstetGynecol. 2005;193: 2062-2066..
Namnoum AB, Hickman TN, Goodman SB, Gehlbach DL, Rock JA. Incidence of symptomrecurrenceafterhysterectomyforendometriosis. Fertil Steril. 1995; 64: 898-902.
Bazot M, Lafont C, Rouzier R, Roseau G, Thomassin-Naggara I, Darai E. Diagnosticaccuracy of physicalexamination, transvaginalsonography, rectalendoscopicsonography, andmagneticresonanceimagingtodiagnosedeepinfiltratingendometriosis. Fertil Steril 2009;92:1825–1833
Hudelist G, English J, Thomas AE, Tinelli A, Singer CF, Keckstein J. Diagnosticaccuracy of transvaginalultrasoundfornoninvasivediagnosis of bowelendometriosis: systematicreviewand meta-analysis. UltrasoundObstetGynecol. 2011;37:257–263.
Stratton P, Winkel C, Premkumar A, Chow C, Wilson J, Hearns-Stokes R, Heo S, Merino M, Nieman LK. Diagnosticaccuracy of laparoscopy, magneticresonanceimagingandhistopathologicexaminationforthedetection of endometriosis. Fertil Steril. 2003; 79: 1078 –1085
Mol BW, Bayram N, LijmerJG,Wiegerinck MA, BongersMY, van der Veen F, Bossuyt PM. Theperformance of CA-125 measurement in thedetection of endometriosis: a meta-analysis. Fertil Steril. 1998;70:1101–1108.
Kennedy S, Bergqvist A, Chapron C, D’Hooghe T, Dunselman G, Greb R, Hummelshoj L, Prentice A, Saridogan E, ESHRE Special InterestGroupforEndometriosisandEndometriumGuideline Development Group. ESHRE guidelineforthediagnosisandtreatment of endometriosis. Hum Reprod. 2005;20:2698–2704.
Ling FW. Randomizedcontrolledtrial of depotleuprolide in patientswithchronicpelvicpainandclinicallysuspectedendometriosis. PelvicPainStudyGroup. ObstetGynecol. 1999;93:51–58.
Oral E, Ilvan S, Tustas E, Korbeyli B, Bese T, Demirkiran F, et al. Prevalence of endometriosis in malignantepithelialovarytumours. Eur J ObstetGynecolReprodBiol. 2003;109(1):97-101.
Wentzensen N, Poole EM, Trabert B, White E, Arslan AA, Patel AV, et al. OvarianCancer Risk FactorsbyHistologicSubtype: An Analysis FromtheOvarianCancerCohortConsortium. J ClinOncol. 2016;34(24):2888-98.
BounousVE,Ferrero A, Fuso L, Ravarino N, Ceccaroni M, Menato G, et al. Endometriosis-associatedOvarianCancer: A DistinctClinicalEntity? AnticancerRes. 2016;36(7):3445-9.
(Dochez V, Caillon H, Vaucel E, Dimet J, Winer N, Ducarme G. Biomarkersandalgorithmsfordiagnosis of ovariancancer: CA125, HE4, RMI and ROMA, a review. J OvarianRes. 2019;12(1):28.
Gentry-Maharaj A, Burnell M, Dilley J, Ryan A, Karpinskyj C, Gunu R, et al. Serum HE4 anddiagnosis of ovariancancer in postmenopausalwomenwithadnexalmasses. Am J ObstetGynecol. 2020;222(1):56.e1-.e17.--12
Chen L, Wang X, Shu J, Xu S, Wu Q, Yu Y. Diagnosticvalue of serum D-dimer, CA125, andneutrophil-to-lymphocyteratio in differentiatingovariancancerandendometriosis. Int J GynaecolObstet. 2019;147(2):212-8.
Inceboz U. Endometriosisaftermenopause. WomensHealth (Lond). 2015;11(5):711-5
Ferrero S, Venturini PL, Gillott DJ, Remorgida V, Leone RobertiMaggiore U. Hemostasisbybipolarcoagulationversussütüreaftersurgicalstripping of bilateralovarianendometriomas: a randomizedcontrolledtrial. J Minim InvasiveGynecol. 2012; 19: 722-730.
Moen MH, Rees M, Brincat M, Erel T, Gambacciani M, Lambrinoudaki I, Schenck-Gustafsson K, Tremollieres F, Vujovic S, Rozenberg S; EuropeanMenopauseandAndropauseSociety. EMAS positionstatement: Managingthemenopause in womenwith a pasthistory of endometriosis. Maturitas. 2010; 67: 94-97.
Brown J ve Farquhar C. Endometriosis: an overview of CochraneReviews. Cochrane Database SystRev. 2014; 3: Cd009590.
Leyland N, Casper R, Laberge P, Singh SS, Sogc. Endometriosis: diagnosisandmanagement. J ObstetGynaecol Can. 2010; 32: S1-32.
StreuliI,deZiegler D, Santulli P et al. An update on thepharmacologicalmanagement of endometriosis. ExpertOpinPharmacother 2013; 14:291–305
Lockhat FB, Emembolu JO, Konje JC. Theevaluation of theeffectiveness of an intrauterine-administeredprogestogen (levonorgestrel) in thesymptomatictreatment of endometriosisand in thestaging of thedisease. Hum Reprod 2004; 19:179–84
Vercellini P, Frontino G, De Giorgi O et al. Comparison of a levonorgestrel-releasingintrauterinedeviceversusexpectantmanagementafterconservativesurgeryforsymptomaticendometriosis: a pilot study. Fertil Steril 2003; 80:305–9
Fedele L, Bianchi S, Zanconato G et al.Use of a levonorgestrel-releasingintrauterinedevice in thetreatment of rectovaginalendometriosis. Fertil Steril 2001; 75:485–8.
Petta CA, Ferriani RA, Abrao MS, Hassan D, Rosa ESJC, Podgaec S, Bahamondes L. Randomizedclinicaltrial of a levonorgestrelreleasingintrauterinesystemand a depotGnRHanalogueforthetreatment of chronicpelvicpain in womenwithendometriosis. Hum Reprod. 2005; 20: 1993-1998.
