Postmenopausal Endometriosis

Endometriosis is a disease of reproductive age group is no longer true. Postmenopausal endometriosis accounts for 2-5% of postmenopausal women. It should be considered as a differential diagnosis if the symptoms are suggestive of endometriosis, though majority of them present with nonspecific symptoms. It is unclear that postmenopausal endometriosis is due to recurrence/reactivation of pre-existing endometriosis or as a de novo condition. Retained hormonal responsiveness and local estrogen productive mechanisms with positive feedback cycle emerged as potential mechanisms. Obesity, phytoestrogens, menopausal hormonal therapy and tamoxifen therapy are considered as risk factors.  There is a potential malignant transformation of 1%. Gold standard of diagnosis of postmenopausal endometriosis is laparoscopic visualization and biopsy. Histological diagnosis is mandatory due to risk of malignant transformation and coexisting malignancies at this age group. Hysterectomy, bilateral salpingo-oophorectomy and complete excision of endometriotic lesions are considered as the first line treatment modality in postmenopausal endometriosis due to risk of malignancy. Aromatase inhibitors, progestogens and GnRH analogues are considered as second line treatment if surgery is contraindicated or if there is a recurrence following surgery. Follow up MRI scan in 6 months needs to be considered and further follow up should be planned individual basis. There are no evidenced based management guidelines for postmenopausal endometriosis due to scarcity of good quality data and multicentre randomized trials or large observational studies are required for further evaluation of postmenopausal endometriosis.