In the late 1970s and early 1980s, many of you may remember reading about endometriosis as the Career Woman's Disease. It was so called because it supposedly only affected childless women in their 30s. Today, we know so much more. Endometriosis is now classified as a hormonal and immune-system disease that can affect females from childhood well into old age. In endometriosis, tissue that lines the uterus (endometrium) is found outside the uterus in other areas of the body such as the ovaries, bladder, rectum and intestines. Every month this tissue builds up and sheds during the menstrual cycle, developing into growths or implants that can cause pain. Many women diagnosed with endo may be looking forward to menopause as a time of relief from the pain. Many do experience a reprieve, but new studies show that symptoms may also reappear. In fact, some women may be diagnosed with endo for the first time at menopause or later.
To fill you in on the latest information about endometriosis at menopause, we've excerpted parts of a chapter from the recently released Endometriosis: The Complete Reference for Taking Charge of Your Health, by Mary Lou Ballweg, founder, president and executive director of the U. S.-basedEndometriosis Association.
Will your endo symptoms resolve with menopause? Should you use hormone replacement therapy, or will it reactivate the endo? Even if the endo implants don't recur, what other health problems should you be aware of? There are no easy answers to these questions and few guideposts for the generation of endoknowledgeable Baby Boomer women now entering menopause.
As you enter your postmenopausal years, you may find that endo no longer plays a central part in your health and life (although that's not the experience for all women with endo; read on). But it's critical that you not stop thinking of yourself as a woman with healthcare needs and health risks. Endo pain may be gone, and fertility may no longer be an issue, but you may face other health problems related to immune system dysfunction-allergies, autoimmune diseases, cancers.
Endo implants, if they have not been removed surgically, may still exist, but the symptoms may no longer be a problem. There are only a few studies in the medical literature about recurrence of endo lesions in menopause (or about appearance of new endo lesions-it may be hard to tell the difference). We now understand mat the lesions of endo depend on estrogen for their growth. It seems reasonable, therefore, to conclude that the lesions would no longer be stimulated when the ovaries produce less estrogen in menopause and monthly bleeding stops. However, smaller amounts of estrogen are still being produced. We don't yet know how large a factor this might be in women who experience continued endo growth and symptoms. Nor do we know what role the immune system, exposure to environmental toxins, diet, lifestyle choices, weight, and other factors play in endo after menopause.
So what do we know about the incidence of endo symptoms in natural menopause? According to some studies, it is estimated that two to five percent of postmenopausal women have endo, including women up to age 76. Another source shows that an estimated two to four percent of postmenopausal women treated at one institution were diagnosed with endo for the first time during surgery for other problems-42 percent had not been using hormone replacement therapy (HRT). This could contradict the belief that endo needs premenopausal levels of estrogen or added estrogens, such as HRT, to thrive.
Women who have had their ovaries removed may find that, in spite of the challenges of being thrown suddenly into menopause, they have finally seen the end of excruciating pelvic pain and other symptoms of endo. We know differently. The Association's data show that endo symptoms continued in 35.7 percent of 731 women who had undergone surgical menopause. In another study of postmenopausal women with chronic pelvic pain, endo was found during laparoscopy in 37 percent of 65 women whose uterus and ovaries had been removed. As well, new endo was found in 13 percent (three cases), but these may represent endo undiagnosed at the first surgery. The incidence of endo was more common in women who had used estrogen replacement therapy (ERT) after their initial surgery.
If you experience endo symptoms in menopause
Be stubborn if you are worried! Try to find a gynecologist who has experience in treating endo. If you see a general surgeon for bowel pain, be aware that she may not consider endo (or the gastrointestinal problems of those with endo) as a possibility. Make sure the surgeon or gynecologist knows about your history with endo. Insist on a rectovaginal bimanual exam; not all doctors do this routinely. If there is tenderness, you may have endo; if not, the pain may be caused by adhesions from previous surgeries and old endo.
Treatment options for peri- and postmenopausal endo
Medical therapy is even less understood in postmenopausal women with endo than in those with perimenopausal endo. Side effects of danazol [a drug that diminishes luteinizing hormone, halting ovulation] increase the risk of problems in women with severe high blood pressure, congestive heart failure or impaired kidney function. We might be dealing not only with endo in menopause, but also with age-related medical problems [e.g. heart disease] that must be considered as well.
Unless there are medical or other reasons not to do this, some endo experts suggest that the procedure of choice in postmenopausal women is "definitive" surgery. This means the complete removal of all visible endo, the uterus, tubes, ovaries and adhesions (when possible). This is a contentious issue. While a number of endo experts emphasized the importance of cutting out all visible endo, not all agreed that the ovaries must also be removed, even in menopause.
In women who have already been castrated and continue to experience endo symptoms, surgery can be done to confirm that endo tissue is still present, to rule out cancer, and to remove all visible endo.
Hormone replacement therapy
The question of whether or not hormone replacement therapy is a safe and helpful option for women with endo is of great concern to many women. Unfortunately, we cannot simply look to the medical literature for guidance. Studies on HRT are usually not specific to women with endo.
Many women are concerned HRT might reactivate their endo. When speaking with your doctor about HRT, be sure to ask how it can help reduce bothersome menopausal symptoms, but also discuss the risks. Of specific concern to women with endo are breast and ovarian cancer, non-Hodgkin's lymphoma, melanoma, and transformation of endo into cancer. [The book has a chapter explaining the strong association of endo with these cancers.]
Unlike the synthetic and animal-derived hormones [such as Premarin and Provera], bio-identical hormones have exactly the same chemical structure as the hormones that women's bodies produce. They include the three estrogens (estradiol, estriol, and estrone in products such as Estrace, Vivelle, Climara, and Estraderm patches) and micronized progesterone (such as Prometrium and Crinone vaginal gel). According to pharmacist Maria Ahlgrimm, R.Ph., an Association Advisor and co-author of The HRT Solution, bio-identical hormones have a different biological effect than synthetic or animal-derived hormones. They fit like a key in a lock, into the hormone receptors, making the hormones readily available within the body and better able to be broken down and eliminated. [No long-term clinical trials comparable to the Women's Health Initiative have been conducted on bioidentical hormones. Risks are unknown.]
Endo and osteoporosis
A number of risk factors for osteoporosis are particularly relevant for women with endo:
* Hormonal treatments (such as GnRH agonist therapy) that purposely reduce estrogen levels
* Hormone imbalances, including problems with progesterone (a bone-stimulating hormone)
* Gastrointestinal problems that could lead to poor absorption of bone-building minerals and other nutrients
* Severe allergic disease, which increases body acidity, resulting in minerals being pulled from the bones to balance blood pH
Hormone therapy is now commonly used as addback therapy in premenopausal women who use GnRH agonists (the agonists put them into a "pseudomenopause"). Because women using the agonists can lose up to six percent of bone mineral density in the first six months of use, estrogen is added (usually with progestin or progesterone) to reduce this bone loss and allow the use of the therapy for longer than six months. We don't know at thus time if repeated use of GnRH agonists will result in women entering menopause with below-average bone density. We also don't know if add-back therapy successfully prevents bone loss; some studies show that it doesn't completely.
One author suggests a baseline bone density test before starting GnRH therapy to determine wherner you have high or low bone density to start. A urine test (NTx) can also determine the rate of bone breakdown, which can help you and your doctor adjust your dose and type of HRT, or lead you to consider it, to prevent further bone loss.
From ENDOMETRIOSIS by Mary Lou Ballweg and the Endometriosis Association. Copyright @ 2004 by the Endometriosis Association. Reprinted by permission of the McGraw-Hill Companies, www.books.mcgraw-hill.com (ISBN 0-07-141248-4) All rights reserved. US$17.95 CDN$25.95, pp. 494, including 36 pages of footnotes.
Copyright Initiatives for Women's Health, Inc. Nov/Dec 2003
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