Can i get endometriosis after a hysterectomy

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A message has been sent to your recipient's email address with a link to the content webpage. Your name: is required Error: This is required. A first vaginal biopsy under local anesthesia produced two small fragments of endometrial tissue with no atypia or malignancy Figure 2. The biopsies did not contain any other tissue and no vaginal epithelium was found. Given the small size of the samples, new biopsies were suggested. Figure 2. Vaginal biopsies. The tissue transmitted for pathological analysis corresponds to endometrium, with numerous glands slightly irregular in size and shape lined by cylindrical cells without nuclear atypia, and densely cellular stroma with signs of ancient bleeding, rare mitotic figures, and no cytologic atypia.

A Hemalun Eosin, magnification x4. B Hemalun Eosin, magnification x The abdominal CT scan and MRI found a hypodense mass adjoining the vaginal dome possibly infiltrating the posterior bladder wall and the rectum Figure 3. The recto-sigmoidoscopy was normal. The CT scan-guided biopsy produced small pieces of endometrium with limited stromal changes mild stroma hyper-cellularity, with no significant atypia and very rare mitotic figures , with no evidence of a malignant tumor Figure 4.

The final pathological diagnosis was: endometrium without malignant features. Figure 3. Comparison of the and CT scanner showing an enlargement of the vaginal mass from 48 x 24 mm to 76 x 47 mm.

Figure 4. CT-scann guided core biopsies of a pelvic mass. This second series of biopsies again samples endometrium with a slightly denser stroma composed of fusocellular cells with rare mitotic figures and no significant atypia. It associates benign epithelial mullerian glands with a stromal component with few atypia close to the endometrial stroma and would be difficult to distinguish on small samples from its counterpart the low grade mullerian adenosarcoma. The results of immunohistochemical techniques, using antibodies against CD10, estrogen receptors, and epithelial markers, though not specific, were consistent with the mullerian adenofibroma hypothesis.

Endometriosis was discussed but not retained because of the notion of hysterectomy in this patient. Surgery was decided after multidisciplinary discussion. Before the surgery, a double J probe was inserted in ureters. Initially, a diagnostic laparoscopy was done, in conjunction with the visceral surgeons, showing a diffuse adherential status resolved by adhesiolysis. Bilateral adnexectomy by laparoscopy followed by a laparotomy conversion in order to extract the whole tumor.

The coagulation and removal of the mass pedicle resulted in a bloc resection of the infiltrated recto-sigmoid with a small part of the vagina. A discharge ileostomy was performed. The operation lasted 8 h and the bleeding amounted to about cc. There were no immediate postoperative complication. Two weeks after the surgery, the patient developed a febrile state with a painful renal percussion and inflammatory syndrome with acute renal failure.

After introducing antibiotic for pyelonephritis, the patient underwent a CT scan that showed a displaced right JJ probe that was removed the following day. The renal insufficiency was probably multifactorial and due to a context of infection, ileostomy liquid loss, toxicity of the antihypertensive drug, and acute tubular necrosis.

The evolution was favorable. The vaginal bleeding stopped after surgery. The ileostomy was closed 3 months later. The pathological analysis of the 75 mm large, highly vascularized, rectosigmoid mass that had developed in the sigmoid meso and the muscularis propria concluded to endometriosis. Both ovaries harbored serous cystadenofibromas left ovary: 2. No malignant neoplasm was found. After phone call with the patient February , she does not report any abdominal pain of vaginal bleeding.

The last imagery and clinical control in Mai was normal. Because of the complex symptomatology and the invasive manner of diagnosis, in the form of laparoscopy with visual findings of the endometriosis lesions 4 , the exact prevalence of this pathology remains unknown. We suppose that an unknown but probably large portion of the population is asymptomatic.

Pain is due to the inflammation-type reaction that gives rise to adhesion and distortion of physiological pelvic anatomy, but the degree of pain is not directly correlated to the severity of the disease Estrogenic stimulation by the ovary during the reproductive phase maintains endometriosis but, after menopause, several mechanisms are supposed to lead to the hormonal continuance which are hormone replacement therapy HRT, without an associated progestin , and other estrogen secretors such as adipose tissue or the adrenal glands.

Studies show that the endometriotic tissue could secrete its own estrogen, confirmed by the possible presence of aromatase expression in these ectopic lesions 11 , Research suggests that the postmenopausal state leads to a certain degree of immunosuppression that could perpetuate endometriosis 13 , but it is not known whether it is a continuation of a past illness or a de novo development Although the physiological ovarian estrogenic secretion is over after menopause, this patient had several risk factors for maintaining a hyper estrogenic state, favorable to endometriosis, such as obesity and HRT Estradiol, 4 years, stopped in before surgery.

Retrospective anamnesis, the patient did not report any pain or fertility issues and the diagnosis of endometriosis was never assumed beforehand. The first choice of treatment of postmenopausal endometriosis is a surgical procedure with optimal cytoreduction, by carbon dioxide ablation, laser, or bipolar diathermy 15 , due to the risk of malignant degeneration Until now, there has been no consensus on the most effective surgical technique to cure peritoneal disease and prevent recurrence Studies show that a patient treated with ablation or excision of endometrioid lesion show a reduction of symptoms such as dyspareunia and pelvic pain The association of endometriosis with an increased risk of malignancies has been described 19 but is debated in the medical literature.

Indeed, women with endometriosis were more likely to develop ovarian cancer than healthy ones 20 , but the causality link is not clearly established. Most of the time, malignant transformation of endometriosis is correlated to endometrioids or clear cell carcinoma of the ovary 7.

The primary remaining question is the frequency of the malignant transformation and, thus far, evidence is not strong enough. It is unclear whether ovarian preservation improves or worsens clinical outcomes in endometriosis, as no randomized controlled trials have addressed this issue.

Data suggest that ovarian conservation with hysterectomy is associated with increased symptom recurrence and higher rates of re-operation. As mentioned previously, Namnoum et al. Similarly, Shakiba et al. Taken together, these studies indicate that women undergoing hysterectomy with bilateral oophorectomy are less likely to require further surgery because of recurrent symptomatic disease Vercillini et al.

Bilateral oophorectomy, and the induction of early menopause, has been associated with increased all-cause mortality and causes specific deaths from coronary heart disease Parker et al.

An additional consideration, especially for younger women, is the widespread effect of estrogen deficiency on psychosexual health. Although MacDonald et al. Further, observational studies have shown that women who have had an oophorectomy more consistently report dissatisfaction with their sexual life post-operatively, when compared to women who have had only a hysterectomy or who have reached physiologic menopause Nathorst-Boos and Van Schoultz, Thus, the physician and patient must carefully weigh the risks and benefits of hysterectomy with and without ovarian preservation.

Recurrent endometriosis has been associated with the presence of residual ovarian tissue following oophorectomy Dmowski et al. Dense pelvic adhesions, inflammatory conditions, such as endometriosis, peri-operative bleeding, and ovaries which are partially or wholly retroperitoneal, can all contribute to the unintentional preservation of ovarian fragments Kho and Abrao, For this reason, care should be taken to meticulously remove ovarian tissue during the initial oophorectomy with clear surgical margins.

Pre-menopausal levels of serum FSH and estradiol in a patient after definitive surgery for endometriosis may indicate the existence of a functional ovarian remnant Kho and Abrao, Of course, HRT must be stopped for at least ten days prior to testing. Menopausal levels of FSH and estradiol do not preclude ovarian remnants, however, as some are less functional than others. Ultimately, histological confirmation of the ovarian tissue is needed to confirm the diagnosis Rizk and Abdalla, If imaging demonstrates residual ovarian tissue, surgical removal with histological confirmation is recommended.

If not, pharmacological suppression of ovarian function can be attempted with GnRH agonists, danazol, or progesterone. There is no clear recommendation on the initiation of hormonal replacement therapy HRT following hysterectomy with oophorectomy for women with a history of endometriosis, but the general consensus is that the benefits outweigh the risks.

The most recent guidelines state only that HRT is not contraindicated, as there is insufficient outcome-based evidence to support recommending HRT after definitive surgery ACOG practice Bulletin, The risk of HRT is two-fold: 1 disease recurrence and 2 malignant transformation of residual disease foci; but these risks have not been clearly defined Oxholm et al.

The exact incidence of disease recurrence with HRT is not known. Matorras et al. The mean follow-up time was 45 months. The recurrence rate was 3. Two of these patients required re-operation. There was no recurrence in women who did not receive HRT. They concluded that the risk of recurrence is low, but additional care should be taken in cases of peritoneal involvement. Soliman and Hillard performed a thorough review of the literature on HRT after surgery for symptomatic endometriosis and recommend the use of continuous tibolone or combined estrogen and progesterone beginning immediately post-operatively, though they note that a strong evidence base for their recommendation is lacking.

Combined estrogen and progesterone therapy should be considered when there is documented residual endometriosis after radical surgery, in cases of severe disease, and in obese patients with higher levels of endogenous estrogen. The addition of progestin is hypothesized to reduce the chance of hyperplasia or malignant transformation in residual disease foci, as endometriotic tissue has both estrogen and progesterone receptors Nisolle et al.

It should be noted, however, that the addition of progestin long-term hormone therapy might increase the risk of post-menopausal breast cancer Rossouw et al. Tibolone is a gonadomimetic, which shows promise in preventing recurrent endometriosis after pelvic clearance. Its active metabolite causes atrophy of the endometrial tissue and theoretically has the same effect on ectopic endometriotic tissue as well Soliman and Hillard, It should be noted that there is currently no evidence to suggest that combined HRT or tibolone reduces the risk of endometrioid adenocarcinoma.

Moreover, some data link combined HRT and tibolone with recurrent endometriosis as well Sundar et al. Soliman and Hillard recommend initiating HRT immediately post-operatively.

Early HRT minimizes hypoestrogenic symptoms menopausal symptoms, urogenital atrophy, loss of libido, and bone loss , and there is evidence that early initiation does not increase the incidence of symptom recurrence following definitive surgery for endometriosis when compared to late initiation. Further, after adjusting for covariates, the group who delayed hormone replacement had a relative risk of 5. Other factors involved in disease persistence may be the local expression of aromatase activity and the varying activity of estrogen and progestin receptors in both primary and recurrent endometriotic tissue.

It has been shown that eutopic endometrial tissue and endometriotic implants express aromatase, which may lead to autologous estrogen production to promote self-growth Noble et al. Some hypothesize that the abnormal hormonal responsiveness of endometrial implants plays a role in the recurrence of endometriosis after hysterectomy. Endometriotic tissue contains a lower concentration of estrogen and progesterone receptors than normal endometrium, and the regulation of these receptors is dissimilar as well Bergqvist et al.

Recurrent endometriosis has still different levels in estrogen and progesterone receptors, which suggests different hormonal regulation Bergqvist and Ferno, It is not surprising, then, that endometriosis recurring or persisting after hysterectomy occurs in a relatively unpredictable manner. Aggressive, hormone-resistant endometriosis arising after hysterectomy and oophorectomy has been documented Metzger et al.

Further histological characterization of the tissue showed elevated progesterone receptor content, despite administration of large amounts of depo-medroxyprogesterone acetate.

The lack of down-regulation points toward the undiscovered alterations in regulatory response in these recurrent lesions. Alternatively, poor vascularity, fibrosis, or exposure to various inflammatory cells may contribute to the non-responsiveness of some endometrial implants Berlanda et al.

Endometriosis has been reported after laparoscopic supracervical hysterectomy LSH with morcellation of the uterine corpus Schuster et al. In LSH, the uterus is morcellated and removed from the pelvis while the cervical stump remains. Many surgeons prefer LSH because of its technical ease, reduced blood loss, reduced operating room and recovery time Schuster et al. Some propose that morcellation of the uterus in the abdomen seeds the peritoneal cavity with endometrial tissue, predisposing the patient to new onset or recurrent endometriosis Hilger and Margina, ; Sepilian and Della Badia, Others hypothesize that retrograde flow of residual endometrial tissue from the retained cervical stump leads to endometriosis following LSH Schuster et al.

Further, one cannot exclude that endometriosis may have been present, but not well visualized at the time of the original surgery; and onset of symptoms only represents worsening of the original disease. Schuster et al. One hundred and two patients had endometriosis at the time of hysterectomy, 60 in the LSH group and 42 in the control group.

The incidence of newly diagnosed endometriosis was 1. Recurrent endometriosis following LSH occurred in 3. At conclusion, the group states that it is inconclusive whether or not uterine morcellation leads to a higher recurrence rate of endometriosis as compared to total hysterectomy, as their results did not reach statistical significance. We await prospective, randomized clinical trials for further evaluation of this surgical technique and its effect on endometriosis recurrence.

MacDonald et al. Additionally, younger women were more likely to report a sense of loss, and to report more disruption from pain in different aspects of their lives. The tailored radical hysterectomy included removal of the uterus, adnexa, posterior and anterior parametria, including endometriotic lesions and upper one-third of the vagina with lesions of lateral and posterior vaginal epithelium.

Tailored radical hysterectomy was associated with a 60 minute increase in operating room time and 1. However, the overall benefit may be in reduced rates of re-operation, although this was not explicitly studied.

Perhaps the best management for recurrence is prevention accomplished by thorough removal of all endometriotic lesions at the time of hysterectomy, including deep lesions of the pouch of Douglas, anterior pouch, and ureter. Although, this is more technically demanding, and requires longer surgery and post-operative stay, there is less recurrence even with HRT Fedele et al. In the case of symptomatic recurrence following hysterectomy, the clinician must have a high suspicion for deep or obstructing lesions.

Therefore, it may be necessary to perform barium enema and sigmoidoscopy if a stricture is suspected, fat-suppressed MRI to identify deep disease, and intravenous urogram for hydronephrosis and hydroureter Clayton et al. The use of GnRH agonists is controversial in the case of recurrence following definitive surgery. If the ovaries have been removed, gonadotropin suppression should not induce hypoestrogenemia.

However, endometrial tissue has been shown to have gonadotropin receptors, and some authors report success with early diagnosis, cessation of HRT, and a 3-month trial of GnRH agonist Matorras et al. If surgery is deemed necessary, laparoscopic excision should be performed using sharp dissection or monopolar electroexcision, as endometriosis be invasive Martin et al.

All visible endometriosis should be removed. Robotic-assisted laparoscopy is of tremendous value in the visualization of lesions and in the meticulous resection Fig. It is also important to make sure interstitial cystitis is excluded as a cause of pelvic pain Fig. Bowel and ovarian adhesions are frequently encountered in patients with pelvic endometriosis after hysterectomy performed for pelvic endometriosis Fig.

Laparotomy, partial, full-thickness or segmental bowel resections, or ureteric stenting may be necessary as well. Patients should be given a bowel preparation before the procedure. For women with endometriosis, hysterectomy is often viewed as a permanent solution to their chronic pelvic pain.

For many women, this is the case. Women who choose to keep one or both ovaries or start HRT after oophorectomy are at higher risk for recurrence, although the benefits of ovarian conservation or HRT in younger women likely outweigh the risk of disease recurrence. Many theories have been proposed as to why endometriosis would recur after hysterectomy, including residual microscopic foci, hormonal factors, ovarian remnants, uterine morcellation, lymphovascular invasion, and de-novo disease.

It is likely, however, that most cases of disease recurrence after hysterectomy are actually cases of disease persistence. It is hard to decipher from the studies that looked at the incidence of disease recurrence after hysterectomy whether or not thorough excision of all endometriotic lesions was performed at the time of the primary surgery. It has been shown that there is a lower rate of recurrence with complete removal of all endometriotic lesions at the time of hysterectomy, although this is a more technically demanding surgery.

With this in mind, surgeons who are familiar and comfortable with the identification and excision of endometriosis should handle hysterectomy for the primary diagnosis of endometriosis. If this is not the case, the patient should be referred to a surgical centre with more expertise in endometriosis. National Center for Biotechnology Information , U. Facts Views Vis Obgyn.

Rizk , 1 A. Fischer , 2 H. Lotfy , 1, 3 R. Turki , 1, 4 H. Zahed , 4 R.