Superficial disease decreases each year as deep lesions increase, but ‘peak endo’ might be the natural stopping point in progression.
Disease progression appears to level out at age 30–33 years, according to findings from a large, multicentre international prospective cohort of patients undergoing surgery for deep endometriosis.
Analysis of the British Society for Gynaecological Endoscopy (BSGE) endometriosis centres database found the odds of superficial endometriosis decreased by 3% each year, while deep endometriosis continued to increase at different rates across anatomical sites.
All patients aged 10–55 years between 2009 to 2021 in the database were included, totalling 14,670 cases from 104 centres across seven countries. The mean age of surgery was 35.9 years.
The researchers found that older patients had more deep lesions and ovarian endometriomas at the time of laparoscopy, and the total number of sites affected by endometriosis increased by 0.12 sites per year. However, there was no correlation with age after 32.8 years of age.
Specifically, they found that bowel lesions and uterosacral ligament lesions increased by 7% and 4% per year, respectively, until about 33 years of age, while deep pelvic sidewall lesions increased by 7% each year until about 31 years of age.
After those ages, the prevalence stopped increasing.
Bladder endometriosis behaved a bit differently, increasing 12% per year until about 28 years of age, then decreasing by 2% each year.
Ovarian endometriomas continued past the proposed plateau, increasing rapidly early on (about 20% per year from age 10 years) and peaking in prevalence at around 41 years of age.
Overall, endometriosis lesions tended to become deeper, involve more sites and include ovarian endometriomas as patients aged, but the progression largely flattened out after age 30.
Dr Tal Jacobson, senior staff specialist in obstetrics and gynaecology at the Mater Hospital Brisbane and senior clinical lecturer at the University of Queensland described the paper as “powerful”.
“It’s definitely a big study. I think it does imply there is some progression of more severe endometriosis with age which, I guess, is an intuitive thought anyway. But it does, quite surprisingly to me, suggest that that peak occurs quite early at 30 or thereabouts for most of these conditions. This is earlier than I would have expected or anticipated,” he told The Medical Republic.
“It is quite useful to know, sort of, quite clear progression of development of pathological endometriosis with age. I don’t think there’s any secret about that – people have generally assumed that – but it does help give that sort of natural history, aetiology, progression of endometriosis, a bit more academic rigor and certainty.”
Related
However, he pointed out some significant restrictions in interpreting the findings.
“This particular study only includes those women who had what they described as a pararectal dissection. To be honest, if you’re in those spaces, it’s already quite advanced, or you’re trying to protect the ureter in ways that we may have moved on from now with the use of ICG [indocyanine green imaging] and stuff like that,” he said.
“It’s a very specific cohort of patients within, probably, the more severe end of it [and] we don’t really know what the purpose of the surgery was.”
Additionally, the research provides no outcomes, such as fertility, pain or repeat surgery, nor does it include information on whether the patients tried medical therapy to suppress the endometriosis, such as the pill or Mirena IUD.
There was no way of using this paper to provide reassurance, Dr Jacobson explained, and as fertility started to decline significantly at age 35, ‘peak endo’ was also associated with the start of this decline.
From a symptomatic point of view, he said the plateau doesn’t necessarily mean that endometriosis suddenly stops getting worse in your early 30s.
“Generally, we say that endometriosis stops when you go through the menopause and most of your pain symptoms resolve,” he said.
“That’s not completely true, particularly since a lot of women are now using HRT again – there’s been a huge increase in the use of HRT over the last five or so years. If women did have endometriosis that would have sort of resolved with menopause, they maybe continued to promulgate it by the use of HRT.
“Quite often, even if they’ve had a hysterectomy, people add in progesterone therapy to try and sort of dampen down any endometriosis after the menopause that could be caused by the estrogen component of the therapy.
“I think the discussion of endometriosis and menopause is really just starting.”
