AUST.AND N.Z. JOURNALOF OBSTETRICS AND GYNAECOLCIGY
384
DISCUSSION It has been known for a long time that honey can accelerate wound healing, for it possesses a property which causes debridement, hastens absorption of oedema and is bacteriocidal. It creates deodorization of infected wounds, promotes granulation tissue foration and accelerates epithelialization (1-6). Previous reports on the use of honey focused on the treatment of shallow wounds such as from burn injury or superficial ulcers (1-4). In this study we have shown that honey can also be used in deeply infected abdomnal wounds after Caesarean section with effective results. The treatment is simple and inexpensive. The honey need not be sterile as it already possesses a bacteriocidal property. This only holds true if the material is without any artefacts. It is prudent to check this by putting a drop of the honey on filter paper; pure and uncontaminated honey will not pass through it. The bacteriocidal activity of honey was also demonstrated by this study, the wounds becoming sterile within 1 week of treatment. This bacteriocidal effect may be due to an inhibine-bacteriocidal substance present in honey, low pH and hygroscopic properties of honey (6).
In this study we achieved excellent results in every case in terms of efficacy, length of hospitalization and patient’s satisfaction. We have shown that honey application with wound approximation by micropore tape is an alternative method in the treatment of abdominal wound disruption and is certainly worthwhile in developing countries where cost and availability of medical facilities are limited.
References 1. Cavanagh D, Beazler J, Ostapowiez F. Radical operation for
2. 3. 4. 5.
6.
carcinoma of the vulva, a new approach for wound healing. J Obstet Gynaecol Br Commonw 1968; 77: 1037-1040. Blomfield R. Honey for decubitus ulcers. JAMA 1973; 224: 905. Effem SSE. Clinical observations on the wound healing properties of honey. Br J Surg 1988; 75: 679-681. Subrahmanyam M. Topical application of honey in treatment of burns. Br J Surg 1991; 78: 497-498. White JW, Subers MM, Scheparts AI. The identification of inhibine, the antibacterial factor in honey, as hydrogen peroxidase and its origin in a honey glucose oxidase system. Biochem Biophys Acta 1963; 73: 57-70. Bergman A, Yanal J, Weiss J, Bell D, David MP. Acceleration of wound healing by topical application of honey. An animal model. Am J Surg 1983; 145: 374-376.
Aust NZ J Obstet Gynaecol
1992; 32: 4: 384
Postmenopausal Endometrioma and Hormonal Replacement Therapy J. T. W. Goh, MBBS and B. A. Hall, MBBS, FRACOG Department of Obstetrics and Gynaecologj Mater Misericordiae Hospital, Brisbane, Queensland EDITORIAL COMMENT: We accepted this case as its message will interest readers. Rarely the postmenopausal woman who is not taking hormone replacement therapy will present with obstruction of bowel or ureter due to chronic inflammation caused by inactive endometriosis (A,B). A. Macafee CHG, Greer HLH. Intestinal endometriosis: a report of 29 cases and a survey of the literature. J Obstet Gynaecol Br Commonw 1960; 67: 539-555. B. Lam AM, French M, Charnock FM. Bilateral ureteric obstruction due to recurrent endometriosis associated with Hormone Replacement Therapy. Aust NZ J Obstet Gynaecol 1992; 32: 83-84.
Summary: This case of postmenopausal endometrioma following hormonal replacement therapy (HRT) demonstrates the often forgotten possibility of reactivation of endometriosis with HRT. The diagnosis of endometriosis should be considered in a postmenopausal woman who presents with pelvic pain and mass whilst on HRT. 1. Registrar. Address for correspondence: Dr J. Goh, Mater Misericordiae Hospital, Raymond Terrace, South Brisbane, Queensland, 4101.
J. T. W. GOHAND B.A. HALL
Endometriosis is oestrogen-dependent and conditions associated with hypo-oestrogenic states, for example the menopause, result in regression of endometriotic lesions (1,2). Postmenopausal endometriosis is an uncommon disease and when it does occur, it is usually associated with exogenous oestrogen therapy (3-5).
Case report A 54-year-old woman, 7 years postmenopausal, presented with a 5-month history of left iliac fossa pain especially during her monthly withdrawal haemorrhage. Twelve months previously, she was placed on Premarin 0.625 mg daily and Provera 10 mg daily for 12 days a month to treat menopausal symptoms. Of significance, she gave a past history of primary infertility which was not investigated, and recurrent left iliac fossa pain, treated as ‘diverticulitis’. Examination revealed a 10 cm left adnexal mass and a pelvic ultrasound confirmed a large ovarian cyst. At laparotomy, an 8 cm left ovarian chocolate cyst was found adherent to the sigmoid colon. There was scarring of the left broad ligament. The right ovary appeared normal and there were multiple small subserosal fibromyomas. A total abdominal hysterectomy and bilateral salpingoop horectomy was performed. The provisional diagnosis of endometriosis was confirmed on histology. The uterus had extensive adenomyosis and endometriotic deposits were on the serosal surface. The left ovarian cyst was an endometrioma. The right ovary and Fallopian tubes were normal. Postoperatively the woman commenced Premarin again to treat menopausal symptoms, and after 2 years, she remains well with no clinical evidence of endometriosis. DISCUSSION Endometriosis is a common disease and is associated with pelvic pain, dysmenorrhoea and infertility (6). The symptoms of this disease improve with the menopause or with the use of drugs to produce a hypo-oestrogenic state (2,7-9). Postmenopausal endometriosis is a relatively uncommon finding. These women can present with abdominal pain, mass, urinary tract obstruction or abnormal bleeding per vaginam (3,4,10). Most of the reports of women with postmenopausal endometriosis were associated with HRT (3,4,10). Sutton (7) reported that endometriosis does not usually recur even if oestrogen alone is used for HRT. Others state that if oestrogen therapy is combined with testosterone in HRT following total abdominal hysterectomy and bilateral salpingo-
385
oophorectomy for endometriosis, recurrence of the disease can be decreased (7,8). Combining progesterone and oestrogen has also been recommended to reduce the risk of reactivating endometriosis (4). Patients developing postmenopausal endometriosis have been reported following the use of oestradiol implants (4) and oral oestrogen therapy (3,lO). Most of these patients had been on oestrogen replacement therapy for several years before symptoms developed. Our patient, on the other hand, complained of symptoms within 6 months of commencement of HRT and was found to have a large endometrioma within 12 months of treatment. It is generally believed that postmenopausal endometriosis occurs with reactivation of endometriotic lesions which remain even after prolonged periods of low serum oestrogen levels (2,4,5,9). However, Goodman et a1 (3) suggested that endometrial metaplasia may occur under exogenous oestrogen stimulation. Postmenopausal endometriosis is an enigmatic condition. It occurs with oestrogen therapy and rarely without (5). Most, if not all, gynaecologists will have prescribed HRT for menopausal women (with a past history of endometriosis) without recurrence of the disease. The reason for reactivation of endometriosis in some of these women but not in the majority is uncertain. High doses of exogenous oestrogen is not a prerequisite for the development of postmenopausal endometriosis, as illustrated by the patient presented. Endometriosis should be considered in the postmenopausal woman who presents with a pelvic mass whilst on oestrogen therapy.
References 1. Barbiere RL, Gordon AC. Hormonal therapy of endometriosis, the estradiol target. Fertil Steril 1991; 56: 820-822. 2. Metzger DA, Lucianoa AA.Hormonal therapy of endometriosis. Obstet Gynecol Clin Nth Am 1989; 16: 105-122. 3. Goodman HM, Kredentser D, Deligdisch L. Postmenopausal endometriosis associated with hormonal replacement therapy. J Reprod Med 1989; 34: 231-233. 4. Mayonda IT, Neale EJ, Flynn JT, Osborn DE. Obstructive uropathy from endometriosis after hysterectomy and oophorectomy. Eur J Obstet Gynecol Reprod Biol 1989; 31: 195-198. 5. Habuchi T, Okajaki T, Miyakawa M. Endometriosis of bladder after menopause. J Urol 1991; 145: 361-363. 6. Barbiere RL. Etiology and epidemiology of endometriosis. Am J Obstet Gynecol 1990; 162: 565-567. I. Sutton C. The treatment of endometriosis. In: Progress in Obstetrics and Gynaecology, Volume 8. London, Churchill Livingston 1990; Chapter 16. 8. Shaw RW. Treatment of endometriosis. In: Progress in Obstetrics and Gynaecology, Volume 9. London, Churchill Livingston 1991; Chapter 17. 9. Punnonen R, Klemi PJ, Nikkanen V. Postmenopausal endometriosis. Eur J Obstet Gynecol Reprod Biol 1980; 11: 195-200. 10. Peress MR, Sosnowski JR, Mathur RS, Williamson HO. Pelvic endometriosis and Turner’s syndrome. Am J Obstet Gynecol1982; 144: 474-476.
384
DISCUSSION It has been known for a long time that honey can accelerate wound healing, for it possesses a property which causes debridement, hastens absorption of oedema and is bacteriocidal. It creates deodorization of infected wounds, promotes granulation tissue foration and accelerates epithelialization (1-6). Previous reports on the use of honey focused on the treatment of shallow wounds such as from burn injury or superficial ulcers (1-4). In this study we have shown that honey can also be used in deeply infected abdomnal wounds after Caesarean section with effective results. The treatment is simple and inexpensive. The honey need not be sterile as it already possesses a bacteriocidal property. This only holds true if the material is without any artefacts. It is prudent to check this by putting a drop of the honey on filter paper; pure and uncontaminated honey will not pass through it. The bacteriocidal activity of honey was also demonstrated by this study, the wounds becoming sterile within 1 week of treatment. This bacteriocidal effect may be due to an inhibine-bacteriocidal substance present in honey, low pH and hygroscopic properties of honey (6).
In this study we achieved excellent results in every case in terms of efficacy, length of hospitalization and patient’s satisfaction. We have shown that honey application with wound approximation by micropore tape is an alternative method in the treatment of abdominal wound disruption and is certainly worthwhile in developing countries where cost and availability of medical facilities are limited.
References 1. Cavanagh D, Beazler J, Ostapowiez F. Radical operation for
2. 3. 4. 5.
6.
carcinoma of the vulva, a new approach for wound healing. J Obstet Gynaecol Br Commonw 1968; 77: 1037-1040. Blomfield R. Honey for decubitus ulcers. JAMA 1973; 224: 905. Effem SSE. Clinical observations on the wound healing properties of honey. Br J Surg 1988; 75: 679-681. Subrahmanyam M. Topical application of honey in treatment of burns. Br J Surg 1991; 78: 497-498. White JW, Subers MM, Scheparts AI. The identification of inhibine, the antibacterial factor in honey, as hydrogen peroxidase and its origin in a honey glucose oxidase system. Biochem Biophys Acta 1963; 73: 57-70. Bergman A, Yanal J, Weiss J, Bell D, David MP. Acceleration of wound healing by topical application of honey. An animal model. Am J Surg 1983; 145: 374-376.
Aust NZ J Obstet Gynaecol
1992; 32: 4: 384
Postmenopausal Endometrioma and Hormonal Replacement Therapy J. T. W. Goh, MBBS and B. A. Hall, MBBS, FRACOG Department of Obstetrics and Gynaecologj Mater Misericordiae Hospital, Brisbane, Queensland EDITORIAL COMMENT: We accepted this case as its message will interest readers. Rarely the postmenopausal woman who is not taking hormone replacement therapy will present with obstruction of bowel or ureter due to chronic inflammation caused by inactive endometriosis (A,B). A. Macafee CHG, Greer HLH. Intestinal endometriosis: a report of 29 cases and a survey of the literature. J Obstet Gynaecol Br Commonw 1960; 67: 539-555. B. Lam AM, French M, Charnock FM. Bilateral ureteric obstruction due to recurrent endometriosis associated with Hormone Replacement Therapy. Aust NZ J Obstet Gynaecol 1992; 32: 83-84.
Summary: This case of postmenopausal endometrioma following hormonal replacement therapy (HRT) demonstrates the often forgotten possibility of reactivation of endometriosis with HRT. The diagnosis of endometriosis should be considered in a postmenopausal woman who presents with pelvic pain and mass whilst on HRT. 1. Registrar. Address for correspondence: Dr J. Goh, Mater Misericordiae Hospital, Raymond Terrace, South Brisbane, Queensland, 4101.
J. T. W. GOHAND B.A. HALL
Endometriosis is oestrogen-dependent and conditions associated with hypo-oestrogenic states, for example the menopause, result in regression of endometriotic lesions (1,2). Postmenopausal endometriosis is an uncommon disease and when it does occur, it is usually associated with exogenous oestrogen therapy (3-5).
Case report A 54-year-old woman, 7 years postmenopausal, presented with a 5-month history of left iliac fossa pain especially during her monthly withdrawal haemorrhage. Twelve months previously, she was placed on Premarin 0.625 mg daily and Provera 10 mg daily for 12 days a month to treat menopausal symptoms. Of significance, she gave a past history of primary infertility which was not investigated, and recurrent left iliac fossa pain, treated as ‘diverticulitis’. Examination revealed a 10 cm left adnexal mass and a pelvic ultrasound confirmed a large ovarian cyst. At laparotomy, an 8 cm left ovarian chocolate cyst was found adherent to the sigmoid colon. There was scarring of the left broad ligament. The right ovary appeared normal and there were multiple small subserosal fibromyomas. A total abdominal hysterectomy and bilateral salpingoop horectomy was performed. The provisional diagnosis of endometriosis was confirmed on histology. The uterus had extensive adenomyosis and endometriotic deposits were on the serosal surface. The left ovarian cyst was an endometrioma. The right ovary and Fallopian tubes were normal. Postoperatively the woman commenced Premarin again to treat menopausal symptoms, and after 2 years, she remains well with no clinical evidence of endometriosis. DISCUSSION Endometriosis is a common disease and is associated with pelvic pain, dysmenorrhoea and infertility (6). The symptoms of this disease improve with the menopause or with the use of drugs to produce a hypo-oestrogenic state (2,7-9). Postmenopausal endometriosis is a relatively uncommon finding. These women can present with abdominal pain, mass, urinary tract obstruction or abnormal bleeding per vaginam (3,4,10). Most of the reports of women with postmenopausal endometriosis were associated with HRT (3,4,10). Sutton (7) reported that endometriosis does not usually recur even if oestrogen alone is used for HRT. Others state that if oestrogen therapy is combined with testosterone in HRT following total abdominal hysterectomy and bilateral salpingo-
385
oophorectomy for endometriosis, recurrence of the disease can be decreased (7,8). Combining progesterone and oestrogen has also been recommended to reduce the risk of reactivating endometriosis (4). Patients developing postmenopausal endometriosis have been reported following the use of oestradiol implants (4) and oral oestrogen therapy (3,lO). Most of these patients had been on oestrogen replacement therapy for several years before symptoms developed. Our patient, on the other hand, complained of symptoms within 6 months of commencement of HRT and was found to have a large endometrioma within 12 months of treatment. It is generally believed that postmenopausal endometriosis occurs with reactivation of endometriotic lesions which remain even after prolonged periods of low serum oestrogen levels (2,4,5,9). However, Goodman et a1 (3) suggested that endometrial metaplasia may occur under exogenous oestrogen stimulation. Postmenopausal endometriosis is an enigmatic condition. It occurs with oestrogen therapy and rarely without (5). Most, if not all, gynaecologists will have prescribed HRT for menopausal women (with a past history of endometriosis) without recurrence of the disease. The reason for reactivation of endometriosis in some of these women but not in the majority is uncertain. High doses of exogenous oestrogen is not a prerequisite for the development of postmenopausal endometriosis, as illustrated by the patient presented. Endometriosis should be considered in the postmenopausal woman who presents with a pelvic mass whilst on oestrogen therapy.
References 1. Barbiere RL, Gordon AC. Hormonal therapy of endometriosis, the estradiol target. Fertil Steril 1991; 56: 820-822. 2. Metzger DA, Lucianoa AA.Hormonal therapy of endometriosis. Obstet Gynecol Clin Nth Am 1989; 16: 105-122. 3. Goodman HM, Kredentser D, Deligdisch L. Postmenopausal endometriosis associated with hormonal replacement therapy. J Reprod Med 1989; 34: 231-233. 4. Mayonda IT, Neale EJ, Flynn JT, Osborn DE. Obstructive uropathy from endometriosis after hysterectomy and oophorectomy. Eur J Obstet Gynecol Reprod Biol 1989; 31: 195-198. 5. Habuchi T, Okajaki T, Miyakawa M. Endometriosis of bladder after menopause. J Urol 1991; 145: 361-363. 6. Barbiere RL. Etiology and epidemiology of endometriosis. Am J Obstet Gynecol 1990; 162: 565-567. I. Sutton C. The treatment of endometriosis. In: Progress in Obstetrics and Gynaecology, Volume 8. London, Churchill Livingston 1990; Chapter 16. 8. Shaw RW. Treatment of endometriosis. In: Progress in Obstetrics and Gynaecology, Volume 9. London, Churchill Livingston 1991; Chapter 17. 9. Punnonen R, Klemi PJ, Nikkanen V. Postmenopausal endometriosis. Eur J Obstet Gynecol Reprod Biol 1980; 11: 195-200. 10. Peress MR, Sosnowski JR, Mathur RS, Williamson HO. Pelvic endometriosis and Turner’s syndrome. Am J Obstet Gynecol1982; 144: 474-476.
