Tevfik Yoldemir Prof MD MA PhD
Department of Obstetrics and Gynecology, Marmara University Hospital, Istanbul, Turkey
Case report
A 47-year-old perimenopausal woman with abnormal uterine bleeding and dyspareunia was admitted to our hospital. The patient’s rectovaginal exam revealed tenderness at the pouch of Douglas. Her ultrasound showed left endometrioma and adenomyosis. Her past medical history revealed that her left kidney was at the brim of the pelvic inlet. A laparoscopy was performed, showing that the pouch of Douglas was obliterated and confirming an endometrioma measuring 5 cm in the left ovary, which was densely attached to the pelvic side-wall. Bilateral ureterolysis was carried out, starting from the pelvic brim. Right and left pararectal spaces were developed, and the rectovaginal space was opened. The endometriotic tissue was removed meticulously from the ureter. Total laparoscopic hysterectomy left salphingoopherectomy, and right salpingectomy were also performed. The Urologist placed and later removed, a ureteral stent through the left ureter for postoperative prevention of possible inflammatory process, which could have occurred after extensive endometriosis excision.
Commentary
Endometriosis is one of the most common gynecologic diseases of women in reproductive age. Preoperative diagnosis is essential both for preventing the risk of renal dysfunction and managing surgical approach [1]. Patients with ureter involvement are asymptomatic in approximately 30% of cases and due to the non- specific symptoms and silent obstruction, they have the risk of progression to renal dysfunction if untreated [1]. Ultrasound is the first diagnostic method that should be applied for endometriomas. The sensitivity of transvaginal ultrasound was best for intestinal and bladder disease and slightly less accurate for uterosacral and rectovaginal involvement because of poor penetration [2]. Laparoscopy is the reference standard diagnostic tool. MRI has been shown to have higher accuracy in detecting endometriotic lesions and evaluate areas otherwise inaccessible by laparoscopy in the presence of dense adhesions [2]. Therapeutic methods for endometriosis are medical and surgical therapies [3]. While progestins can decrease the volume of endometriomas [4, 5], there is no evidence that medical therapy can prevent the progression of DIE. If any patient takes long-term hormonal treatment for endometriosis-related pain, she needs a follow-up by ultrasonography to timely detect the progression of DIE causing either bowel or ureteral stenosis. Even after menopause, there is the chance for recurrence of endometriosis-related pain [5].
Hormonal treatment of deep endometriosis with progestins, such as norethindrone acetate (NETA), effectively relieves pain in more than 90% of women at one year follow up. NETA can be safely administered in the long-term, may not be expensive and is usually well-tolerated [4,6]. Should this patient have vasomotor symptoms in the future, Estradiol 1 mg + NETA 0.5 mg (Activelle, Novo Nordisk) is an appropriate choice for hormone therapy [7]. A course of 0.45 mg conjugated estrogen/ 20mg bazedoxifene (CE/BZA) (Duavee, Pfizer) could be another valid option [8, 9].
References
- Yoldemir T, Cimsit, C . Ureteral endometriosis: A rare cause of silent obstructive uropathy. Marmara Medical Journal 2016;29 : 117-120. doi: 10.5472/MMJcr.2902.03
- Cimsit C, Yoldemir T, Guclu M, Akpinar IN. Susceptibility weighted magnetic resonance imaging for the evaluation of deep infiltrating endometriosis: preliminary results. Acta Radiol. 2016 Jul;57(7):878-85.
https://pubmed.ncbi.nlm.nih.gov/26315838/ - Ozyurek ES, Yoldemir T, Kalkan U. Surgical challenges in the treatment of perimenopausal and postmenopausal endometriosis. Climacteric. 2018 Aug;21(4):385-390.
https://pubmed.ncbi.nlm.nih.gov/29493295/ - Barra F, Scala C, Ferrero S. Current understanding on pharmacokinetics, clinical efficacy and safety of progestins for treating pain associated to endometriosis. Expert Opin Drug Metab Toxicol. 2018 Apr;14(4):399-415.
https://pubmed.ncbi.nlm.nih.gov/29617576/ - Gemmell LC, Webster KE, Kirtley S, Vincent K, Zondervan KT, Becker CM. The management of menopause in women with a history of endometriosis: a systematic review. Hum Reprod Update. 2017 Jul 1;23(4):481-500.
https://pubmed.ncbi.nlm.nih.gov/28498913/ - Berlanda N, Somigliana E, Frattaruolo MP, Buggio L, Dridi D, Vercellini P. Surgery versus hormonal therapy for deep endometriosis: is it a choice of the physician? Eur J Obstet Gynecol Reprod Biol. 2017 Feb;209:67-71.
https://pubmed.ncbi.nlm.nih.gov/27544308/ - Peeyananjarassri, K., & Baber, R. Effects of low-dose hormone therapy on menopausal symptoms, bone mineral density, endometrium, and the cardiovascular system: a review of randomized clinical trials. Climacteric, 2005; 8(1): 13–23.
https://pubmed.ncbi.nlm.nih.gov/15804728/ - Snyder BM, Beets JW, Lessey BA, Horton SRW, Abrams GA. Postmenopausal Deep Infiltrating Endometriosis of the Colon: Rare Location and Novel Medical Therapy. Case Rep Gastrointest Med. 2018 Feb 14;2018:9587536.
https://pubmed.ncbi.nlm.nih.gov/29666722/ - Flores VA, Stachenfeld NS, Taylor HS. Bazedoxifene-conjugated estrogens for treating endometriosis. Obstet Gynecol. 2018 Aug;132(2):475–477.
https://pubmed.ncbi.nlm.nih.gov/29995747/
