Am Fam Physician. 2000 Aug 15;62(4):734-735.
to the editor: We read with interest the recent review article on endometriosis by Dr. Wellbery.1 We would like to add one additional comment about estrogen replacement therapy following hysterectomy and oophorectomy for symptomatic endometriosis.
We describe the case of a 68-year-old woman who underwent total abdominal hysterectomy and bilateral salpingooophorectomy in 1972 for intractable pelvic pain due to endometriosis. She was subsequently placed on estrogen-only replacement therapy. In November 1999, she presented to her primary care physician complaining of vaginal pressure and bleeding. A pelvic examination revealed a submucosal nodule at the vaginal apex, which was confirmed on pelvic ultrasonography as a 3 × 2.6-cm mass.
The patient subsequently underwent surgical resection with pelvic lymph node dissection. Pathologic examination of the vaginal mass revealed a moderately differentiated endometroid adenocarcinoma (see the accompanying figure). No associated foci of endometriosis were identified.
The increased risk of developing intrauterine endometrial adenocarcinoma with prolonged unopposed estrogen therapy is well established. However, numerous investigators have reported endometrial malignancies arising in endometriotic foci following unopposed estrogen stimulation.2–4 Adenocarcinomas comprise the majority of these tumors, but stromal sarcomas also have been reported.5 Reported sites of malignancy include the vagina, rectum, cul-de-sac and rectovaginal septum.2
According to Sampson,6 who first described adenocarcinoma arising in endometriosis, histologic evidence of endometriosis in close proximity to a tumor should be identified before a definitive correlation between the two can be established. Although we did not see endometriosis in the current case, the patient's history and the site of the tumor were suggestive of an association.
Although unopposed estrogens are commonly administered to women who have undergone hysterectomies, physicians are urged to bear in mind the original indications for the procedure. If the hysterectomy was performed in the context of endometriosis, combined (estrogen and progesterone) hormone replacement therapy should be considered.
1. Wellbery C. Diagnosis and treatment of endometriosis. Am Fam Physician. 1999;60:1753–62.
2. Gucer F, Pieber D, Arikan MG. Malignancy arising in extraovarian endometriosis during estrogen stimulation. Eur J Gynaecol Oncol. 1998;19:39–41.
3. Reimnitz C, Brand E, Nieberg RK, Hacker NF. Malignancy arising in endometriosis associated with unopposed estrogen replacement. Obstet Gynecol. 1988;71(3 pt 2):444–7.
4. Abu MA, Sinha P, Totoe L, McCune G. Endometrial cancer thirteen years after total abdominal hysterectomy and bilateral salpingooophorectomy and hormone replacement therapy: a case report. Eur J Gynaecol Oncol. 1997;18:482–3.
5. McCluggage WG, Bailie C, Weir P, Bharucha H. Endometrial stromal sarcoma arising in pelvic endometriosis in a patient receiving unopposed oestrogen therapy. Br J Obstet Gynaecol. 1996;103:1252–4.
6. Sampson JA. Endometrial carcinoma of the ovary, arising in endometrial tissue in that organ. Arch Surg. 1925;10:1–72.
editor's note: This letter was sent to the author of “Diagnosis and Treatment of Endometriosis,” who declined to reply.
Send letters to Kenneth W. Lin, MD, MPH, Associate Deputy Editor for AFP Online, e-mail: email@example.com, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680.
Please include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.
Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the American Academy of Family Physicians permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.
Copyright © 2000 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact firstname.lastname@example.org for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions