Can endometriosis persist after hysterectomy/ovary removal/menopause?

Can endometriosis persist after hysterectomy/ovary removal/menopause?

Yes, it can:

Endometriosis does not “die off” or go away with a hysterectomy or menopause. Some people do find some relief from their symptoms, but endometriosis can still persist. Endometriosis often has several related or comorbid conditions (such as adenomyosis or fibroids) that share similar symptoms (pain with menstruation, chronic pelvic pain, etc.) that a hysterectomy might help – but it may not stop your symptoms from endometriosis. Endometriosis exists outside of the uterus and can still respond to hormonal influences (Bulun et al., 2002).  Even if your ovaries are removed, endometriosis lesions can produce their own estrogen (Huhtinen et al., 2012). This is important to note because estrogen causes endometriosis lesions to grow and persist (Bulun et al., 2012). So even with the removal of the ovaries or with menopause, endometriosis can sustain itself.

There is high recurrence of symptoms with the removal of just the uterus; but, even with the removal of the ovaries, any endometriosis lesions left behind can continue to grow, progress, and cause symptoms (Clayton et al., 1999; Inceboz, 2015; Khan et al., 2013; Rizk et al., 2014). So, if you have your uterus and ovaries removed for other conditions, it is best that all endometriosis lesions be removed as well. The skill of the surgeon at removing all endometriosis is important. Rizk et al. (2014) report that “the recurrence of endometriosis symptoms and pelvic pain are directly correlated to the surgical precision and removal of peritoneal and deeply infiltrated disease.”

Endometriosis has been found in about 2.2% of postmenopausal women (Zanello et al., 2019). Inceboz (2015) states that “endometriotic lesions remained biologically active, with proliferative activity and preserved hormonal responsiveness, even in the lower estrogenic environment in the postmenopause.” Postmenopausal endometriosis should be managed surgically according to Streuli et al. (2017) and Zanello et al. (2019).

What about hormone replacement if you are in menopause or have had your uterus and ovaries removed? Hormone replacement therapy (HRT) is important as “the hypo-estrogenic state was demonstrated to be a risk factor for cardiovascular and bone disease” (Zanello et al., 2019). While HRT has not been concluded useful for preventing heart disease, it can be useful for those at a higher risk of osteoporosis (Zanello et al., 2019). There isn’t much data available to help guide the decision, but Zanello et al. (2019) report that “in young menopausal women with premature or surgically-induced menopause the benefits of HRT probably overcome the risks” and “in women with residual endometriosis after surgery, the use of HRT should be discussed and the risk of recurrence should be carefully considered before starting an estrogen-based replacement therapy”.  Rizk et al. (2014) also states that “the general consensus is that the benefits outweigh the risks” and that starting HRT soon after menopause does not seem to have a faster rate of recurrence. Zanello et al. (2019) concludes that “based on low-grade evidence in the literature, we recommend prescribing combined HRT instead of unopposed estrogen.” It also depends on if your endometriosis was removed.

Links:

• “Endometriosis persisting after castration: clinical characteristics and results of surgical management”
• “Hysterectomy”

Hysterectomy is the removal of uterus. Oophorectomy is the removal of an ovary. If one has had a hysterectomy, then that person can still have ovaries. If one has had a hysterectomy with bilateral oophorectomy, then that person has had the uterus and both ovaries removed. At that point, you will usually see it as a hysterectomy and bilateral salpingo‐oophorectomy (removal of uterus, fallopian tubes, and ovaries).  It is an important clarification when talking about endometriomas. If both ovaries are removed, endometriomas can reoccur from ovarian remnants (search ovarian remnant syndrome).

• Yildiz, S., Kaya, C., Alay, I., Cengiz, H., Ekin, M., & Yasar, L. (2020). The pain symptoms and mass recurrence rates after ovarian cystectomy or uni/bilateral oophorectomy procedures in patients over 40 years old with endometriosis. Ginekologia Polska, 91(6), 295-300. Retrieved from https://journals.viamedica.pl/ginekologia_polska/article/view/66168

“The recurrence rate following endometrioma surgery was 13.3% in the cystectomy group, 10.3% in the USO group and 6.9% in the BSO group. There were no statistically significant differences in the recurrence rate between the groups. Additionally, a type of recurrence analysis was conducted between the cystectomy group (pain 6.7%, mass 6.7%), USO group (pain 7.7%, mass 2.6%), and BSO group (pain 6.9%, mass 0%); and there were no statistically significant difference within these groups….In different studies evaluating the pathophysiology of recurrence, it has been suggested that the recurrent lesion may derived from remaining tissue. Failure to completely remove pathological tissues at the time of primary surgery may increase the likelihood of recurrence to endometrioma, and the larger part of recurrent lesions were formed in the same area [31–32]. Thus, during the primary surgery for endometriosis, an excellent surgical technique and the experienced endometrioma surgeons are critical due to the capability of pathologic residual tissue to grow.”

*cystectomy- removal of the cyst, USO (unilateral salpingo-oophorectomy)- removal of one ovary and fallopian tube, BSO (bilateral salpingo-oophorectomy)- removal of both ovaries and fallopian tubes

• Meserve, E. E., & Crum, C. P. (2018). Benign conditions of the ovary. In Diagnostic Gynecologic and Obstetric Pathology (pp. 761-799). Content Repository Only!. Retrieved from https://www.sciencedirect.com/topics/medicine-and-dentistry/ovarian-remnant-syndrome

“Ovarian remnant syndrome is defined as the presence of symptomatic residual ovarian tissue, usually following a complete hysterectomy and bilateral salpingo-oophorectomy.175 It is believed to be the result of unintentional residual ovarian tissue left behind during a difficult oophorectomy, as with the dense adhesions associated with endometriosis or multiple prior procedures.176 The typical clinical presentation is pelvic pain and a palpable mass, often following multiple prior pelvic surgical procedures. The actual incidence is not known, but in one study, more than 20% of patients undergoing posthysterectomy laparoscopy for persistent pain and a mass were found to have residual ovarian tissue.177 Residual ovarian tissue is removed by either laparoscopy or laparotomy and may require multiple procedures.”

References

Bulun, S. E., Gurates, B., Fang, Z., Tamura, M., Sebastian, S., Zhou, J., … & Yang, S. (2002). Mechanisms of excessive estrogen formation in endometriosis. Journal of reproductive immunology, 55(1-2), 21-33. Retrieved from https://doi.org/10.1016/S0165-0378(01)00132-2

Bulun, S. E., Monsavais, D., Pavone, M. E., Dyson, M., Xue, Q., Attar, E., … & Su, E. J. (2012, January). Role of estrogen receptor-β in endometriosis. In Seminars in reproductive medicine (Vol. 30, No. 01, pp. 39-45). Thieme Medical Publishers. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4034571/…

Clayton, R. D., Hawe, J. A., Love, J. C., Wilkinson, N., & Garry, R. (1999). Recurrent pain after hysterectomy and bilateral salpingo‐oophorectomy for endometriosis: evaluation of laparoscopic excision of residual endometriosis. BJOG: An International Journal of Obstetrics & Gynaecology, 106(7), 740-744. Retrieved from https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/j.1471-0528.1999.tb08377.x?fbclid=IwAR04aFoLsukqsYutNPNXtJNZpKLNEJbgOOon334NW8D7wvwzZMWaS2YaZts

Huhtinen, K., Ståhle, M., Perheentupa, A., & Poutanen, M. (2012). Estrogen biosynthesis and signaling in endometriosis. Molecular and cellular endocrinology, 358(2), 146-154. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0303720711005041

Inceboz, U. (2015). Endometriosis after menopause. Women’s Health, 11(5), 711-715. Retreived from https://journals.sagepub.com/doi/full/10.2217/whe.15.59

Khan, K. N., Kitajima, M., Fujishita, A., Nakashima, M., & Masuzaki, H. (2013). Toll‐like receptor system and endometriosis. Journal of Obstetrics and Gynaecology Research, 39(8), 1281-1292.  Retrieved from https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/jog.12117

Rizk, B., Fischer, A. S., Lotfy, H. A., Turki, R., Zahed, H. A., Malik, R., … & Herrera, D. (2014). Recurrence of endometriosis after hysterectomy. Facts, views & vision in ObGyn, 6(4), 219. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4286861/

Zanello, M., Borghese, G., Manzara, F., Degli Esposti, E., Moro, E., Raimondo, D., … & Seracchioli, R. (2019). Hormonal replacement therapy in menopausal women with history of endometriosis: a review of literature. Medicina, 55(8), 477. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6723930/